Choptank Community Health System
Program Name: PCMH for Safety Net Diabetic Patients
Grant Amount: $400,000/2 years
Choptank Community Health System is located on the Eastern Shore and is a private, non-profit community health center network, providing access to health care through the delivery of comprehensive medical, dental and behavioral health care services in Caroline, Dorchester, and Talbot Counties. The Choptank program will identify the most out-of-control uninsured diabetic patients with HGBA1C's >9% to participate in year long program that will provide intense management of their chronic illness, including meeting with medical provider every three months for follow up. Each patient will also meet with diabetic educator for 30-60 minutes and develop/evaluate self-management, nutrition counseling, review medications, exercise plans, stress management, and coordination of care (screening test, scheduling for dental exams, etc.). Nurse educators may check on patients via phone calls at more frequent intervals. Patients will be incentivized for participation and success. Grant will support two diabetic health educators, clinical administration, evaluation and reporting, supplies, patient incentives, and ophthalmology support. Choptank anticipates applying this model to the larger chronically ill population.