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Restructuring BTC care management

Restructuring BTC care management. Ellen Chiang. Bridge to care. Mission: Provide free care for patients with chronic diseases and no PCP Bridge patients to care within a year Team: medical, pharmacy, nursing, and social work students. Care management.

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Restructuring BTC care management

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  1. Restructuring BTC care management Ellen Chiang

  2. Bridge to care • Mission: • Provide free care for patients with chronic diseases and no PCP • Bridge patients to care within a year • Team: • medical, pharmacy, nursing, and social work students

  3. Care management • Work with medical team to come up with plan of care that is informed by the patient’s barriers to care • Manage patient communication outside of clinic • Connect patient’s to resources and assistance programs • UNC Charity Care • UNC Pharmacy Assistance • Community Empowerment Fund • Health insurance enrollment

  4. BTC & RACIAL equity IN MEDICINE • BTC Patient Demographics • Seen > 1x in 2018: 40 patients • Hypertension, diabetes, & hyperlipidemia • Over 95% do not have health insurance • >70% black and/or Hispanic patients • People of color face increased barriers to accessing health care1 • Prevalence of diabetes is higher in non-Hispanic black men and Hispanic men2 • Rates of premature death (<75 YO) from stroke & coronary artery disease were higher in non-Hispanic black men & women than among white men & women. 2

  5. CURRENT PROGRESS • Graduate student recruitment: nursing & social work • Care manager handbook • Faculty advisor • Rayhaan Adams: UNC Family Medicine • Community partnerships • Face to face meeting with UNC Charity Care • Establishment of formal relationship with Community Empowerment Fund • Care Manager Training

  6. Continuing Projects • REI Groundwater Training – BTC • Online training for all of SHAC • Patient advisory board

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