Access to Care and Care Coordination

Improve health and reduce health care costs and unnecessary emergency department and hospital admissions though personalized support for our highest risk patients.

PRIME

Tahoe Forest Hospital has a great opportunity to participate in The Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program. We chose two focus areas that aligned with our strategic plan. These include: Chronic Non-Malignant Pain Management and Million Hearts Initiative. These projects were selected because they address the health care needs of our community and support the identified organizational goals and project aims through the utilization of care coordination, prevention and screening programs, and evidenced-based care management tools. The partnerships of medical providers, community members and regional health organizations will build a shared vision of multidisciplinary/multimodal approach to population health management.

Chronic Care Management (CCM)

CCM is a patient and family-centered program that assists people living with two or more chronic conditions better manage their condition. The Care Coordinator assists in teaching self-management skills, goal setting, and effective communication with Primary Care Providers (PCP) and provides links to community resources. Care Coordination services can be home visits, phone calls and accompanying patients to PCP visits. CCM continues for as long as the person has two or more chronic illnesses that are expected to last at least 12 months and that place a person at significant risk of death, acute exacerbation or functional decline.

Transitional Care Management (TCM)

In the TCM program the Care Coordinators' focus is on facilitating a smooth transition from the hospital to the home. The service starts with the coordination of care between the hospital's interdisciplinary team, the patient, family and the Primary Care Provider and continues for 30 days following discharge from the hospital. The Care Coordinator works closely with the patient, family, Primary Care Provider, Home Health Care Staff and other Community Resources to formulate a patient-centered holistic care plan. After 30 days post hospitalization, the patient may consent to enter into the Chronic Care Management program.

Youth Care Management (YCM)

The Truckee North Tahoe (TNT) Youth Health Initiative emerged in 2014 from community-based collaborative efforts to address critical health needs in the region. Local health disparities, rural isolation and the status of adolescent health in the TNT region led to the formation of a regional partnership focused on improving youth health outcomes and addressing persistent health inequities experienced by Hispanic youth. TNT Youth Health Initiative Partners include the Wellness Neighborhood of TFHS, Tahoe Truckee Unified School District, Placer and Nevada County Health and Human Services and the Community Collaborative of Tahoe Truckee.

An in-depth analysis showed Access to Care as a significant need for TNT adolescents. In response, the Wellness Neighborhood developed a Youth Care Management program and hired a Youth Health Navigator to increase access to care, improve health literacy among teens and their parents and improve service integration between the hospital, counties and school district.

Promotore (Community Health Worker) Program

The Promotore Program is a collaboration with the Wellness Neighborhood, North Tahoe Family Resource Center and Family Resource Center of Truckee to address ethnic disparities present in the community. Promotores assist clients in meeting their primary health care needs by identifying and referring clients to community practitioners and activities designed to promote health literacy and self management, good dental health practices, immunizations, physical exercise and healthy diet as well as providing direct services through workshops and one-on-one consultations.