Case Study 2 CHBN

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.1.

Think of other educational activities that would be appropriate for each team

member.

2. Suppose you are organizing health programmes for (a) the teenagers, (b) the

elderly, and (c) the farmers in your community.

3. What would be the responsibility of each health team member in each of these

programmes?

If there is a health programme for teenager’s community health workers can educate them with basic
health care, and other health information, nurses can also have a sex education for the teenagers. A
programme for elderly can be handled by the nurses, so they can examine the health of the elderlies.
For a programme for the farmers in a community, the community social worker can provide assistants
to them, and chw’s to educated them with basic health care like first aid. While the dispensers would
provide medications for the sick.

4. What would be the health education duties of each member?

5. How should other community workers be involved in such programmes

The healthcare team, regardless of whether you’re treated at a large academic institution or a small,
rural private practice, is the group of professionals who contribute to your care and treatment as a
patient. Typical members of a healthcare team are a doctor and a registered nurse. In some cases, there
might be a Nurse Practitioner instead of or as well as a doctor. In others, physical therapists,
occupational therapists, and social workers may be part of the team. Office managers also play an
important role in the healthcare team.

The Community Care Team works with patients and their health care providers to improve patient
health conditions after their hospital stay. Specifically, the team helps ensure patients have a smooth
transition from hospital to home, learn to manage their illness and feel confident in doing so on their
own. Our Community Care Team is a comprehensive support system that includes a Community Health
Worker, Community Health Nurse and Community Social Worker that are trained, certified and
experienced.

The Community Health Worker supports lifestyle and community service needs, such as arranging for
transportation to appointments, establishing food, financial and housing assistance, coordinating home
health care worker, accessing senior programs and helping with proper diet management. The
Community Health Nurse supports the physical health of patients, including assessing their health during
their first home visit, organizing their medication list, providing information to their health care
providers and monitoring their progress. Some patients may need additional emotional support after
their hospital stay. The Community Social Worker supports their mental health wellbeing by assessing
their anxiety symptoms, providing informal counseling and making referrals to behavioral health
providers. The Community Care Team assists patients with solving personal issues that interfere with
medical compliance, providing medication-reconciliation, instructing chronic disease management and
disease-specific education, connecting to community health resources, including primary care, specialist
providers and social service agencies.

Our efforts have resulted in ...

Reduced hospital readmission rates at seven, 30 and 60 days post patient discharge

Service satisfaction ratings raging from moderate to very satisfied from 100 percent of patients

Patients reporting greater access to quality health care

The Team Approach

Our team of nurses and health professionals work with you and your patients to ensure their hospital to
home transition is a smooth process. Our approach teaches patients how to effectively manage their
chronic conditions.

Together we can:

Improve health behaviors and outcomes

Increase treatment plan compliance

Decrease preventable hospitalizations

Reduce high costs of care

Address any social barriers

Hospital-to-Home Transition

Within days of your patient leaving the hospital, a Community Health Nurse and a Community Health
Worker visit the patient at home to assess their physical health, lifestyle and community resource needs.

Our team then meets with your patient to identify goals and create a health action plan that supports
their health and fits their lifestyle. Our team then relays the plan to you for your approval.

In the Program
Patients, who qualify to enroll, work with our team for thirty to ninety days depending on their health
action plan. During this time, our team regularly meets with your patient and is also available as a
resource to you and your staff.

Completion

Our goal is for your patients to improve their health and feel connected to their doctors and community
services.

Eligibility Criteria

Patients must meet the following conditions:

Medicare beneficiary

Two or more encounters with the hospital in the last 12 months, including observation, inpatient and
emergency room visits

A CHW can work in many different roles serving the health care needs of the community to include:

conducting outreach for medical personnel or health care organizations to implement programs in the
community that promote, maintain and improve individual and community health.

helping individuals to encourage the adoption of healthy behaviors and to increase their health
knowledge and self-sufficiency by providing health information and resources, social support and
informal counseling.

advocating for individual and community health needs.

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