The Temple Center for Population Health (TCPH) coordinates and supports patient and family care by focusing on quality indicators and assuring accurate and timely communication between providers and between providers and patients. This is achieved through a variety of programs.
Key Programs for Value Based Care
The TCPH nurse navigators are registered nurses who work with and in physician practices to improve patient outcomes related to quality measures, including the Healthcare Effectiveness Data and Information Set (HEDIS) measures. These measures are focused on management of chronic diseases including hypertension and diabetes; appropriate cancer screening; immunizations; appropriate use of medications and smoking cessation.
The nurse navigators provide both Transitions in care as well as longitudinal care management. The navigators focus on short and long term objectives to manage in the acute care transitions as well as assist patients who manage chronic conditions, such as diabetes, heart failure and COPD. Nurse navigators play a vital role in population health management and improving health outcomes.
In collaboration with the TCPH Transitions of Care Program, the Temple Access Center provides post-acute care contact for patients discharged from the hospital.
The program focuses on scheduling follow-up provider appointments with primary care follow-up appointments, medication management. Complex problems are escalated to nurse navigators.
Temple University is a national leader in training and utilizing community health workers (CHWs) as coaches and support for patients with chronic disease and high utilization of health services. These individuals live and work in our community and visit our patients in their homes to link them with the support they need to enhance their care and health outcomes.
CHWs serve as liaisons between patients and their providers to improve compliance with the care plan and prevent unnecessary emergency department visits and readmissions.
Skilled Nursing Home Collaborative
Initiated by the TCPH, this group of 15 skilled nursing home facilities and rehabilitation centers caring for Temple Health patients is working to reduce readmissions from the post-acute setting by establishing a clinical communication strategy, metric standardization, and a care management competency inventory.
A similar program, called the Home Health Collaborative, was developed with six home health agencies to reduce preventable readmissions by increasing use of the call center for discharge problem solving, development of a surgical wound discharge dressing kit, education on medication reconciliation and documentation, and patient education related to the use of after-hours call systems.
The TCPH pharmacist coordinates with Temple Health ambulatory practices to optimize the use of pharmaceuticals, reconcile medications, avoid polypharmacy in the elderly and implement guidelines for the use of Hepatitis C medications.