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Restructuring BTC care management

Ellen Chiang's Bridge to Care aims to provide free care to chronic disease patients without a primary care provider. The team of medical, pharmacy, nursing, and social work students collaborates to develop personalized care plans based on patient barriers and manages patient communication, resource connections, and insurance enrollment. With a mission to bridge patients to care within a year, this project addresses health disparities faced by black and Hispanic populations in accessing healthcare. Current progress includes graduate student recruitment, care manager handbook, community partnerships, and ongoing projects like REI Groundwater Training and patient advisory board.

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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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