Open Gates is a community-based, nurse-managed clinic sponsored by the University of Maryland School of Nursing (SON) that provides primary care for an underserved, inner city population in southwest Baltimore. Over the past two years, the clinic has utilized the talents of experienced CHWs in traditional roles for patient education, linking patients with resources, and bridging cultural gaps. While undoubtedly valuable, these roles have not been reimbursable under managed care, the primary financing mechanism today. In response, Open Gates has developed an innovative, extended CHW role in disease management, a managed care concept for population-based, evidence-based care that is designed to improve health outcomes and reduce costs. In the Open Gates Hypertension Disease Management program, CHWs follow a Care Pathway, an outline of the home visits needed to complete the program. Each visit consists of a series of specific, structured in-home interventions such as blood pressure monitoring, medication checks, and patient education on treatment adherence, exercise, diet, or smoking cessation. CHW training is followed by daily supervision and support meetings facilitated by SON faculty on site. In order to show that CHWs can function effectively as members of a nurse-managed team implementing disease management programs, Open Gates has developed a randomized clinical trial to study the outcomes of CH W-visited hypertension patients. The CHWs will assist in both the implementation and evaluation of the research. Outcomes examined will include: health status measures, financial outcomes, health knowledge, patient satisfaction, and changes in health practices and attitudes.
Learning Objectives: At the conclusion of the session the participant will be able to: 1)Describe the managed care of concept of disease management. 2)Apply the concept of disease management in defining new roles for CHWs in a managed care environment. 3)Outline the elements needed to create a research evaluation strategy for a new disease management program utilizing CHWs
Keywords: Disease Management, Hypertension
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: Employed by the University of Maryland School of Nursing sponsor of Open Gates Health Center