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 inter-related programs.
Key Programs for High-Value 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 also smooth the way for transitions of care from the inpatient to the outpatient setting, calling patients shortly after discharge to make sure they are managing at home, understand their medications and have access to and appointments for timely post-hospitalization follow-up. Nurse navigators play a vital role in population health management.
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.
TCPH provides chronic disease management services and calcium score screening for defined populations affiliated with organizations that are self-insured. These programs identify individuals at risk for health issues and intervene to prevent progression of disease.
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.
In collaboration with the Temple Access Center, the TCPH Transitions of Care Program provides post-acute care contact for patients discharged with diabetes, congestive heart failure, COPD, pneumonia, falls and complex wounds.
The program schedules follow-up calls to assure that patients are compliant with scheduled appointments and helps resolve open issues. Complex problems are escalated to nurse navigators.
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.