Chronic Conditions

effective at helping patients meet their goals and improve their health and that the CHWs are recognized within clinical settings as a partner in the patients’ care. ChristianaCare’s commitment is to provide care that is radically accessible and tailored to the community. The Health Guide and CHW programs and other core initiatives help individuals overcome barriers and ensure more individuals can obtain health care services, as well as access to the social care resources they need to prioritize and optimize their health.

Chronic Conditions

In its Annual Operating Plan for fiscal year 2023, ChristianaCare has committed to building systems and processes to identify and reduce disparities in quality measures and health outcomes with a focus on chronic disease, cancer, and maternal/infant health outcomes. This is an ambitious aspiration, and the next few years will be spent designing the process to identify and address disparities in these areas.

ChristianaCare is also addressing chronic conditions through several innovative programs that extend beyond clinical spaces and interventions. To participate in the Primary Care CHW program, patients must have hypertension or diabetes or 2 or more Emergency Department (ED) visits in the prior 90 days. In this program, the CHW will assess and address the patients’ Social Determinants of Health, work together with the patient to identify and achieve patients’ personal goals, decrease no show primary care appointment rates, improve patients’ self-management of their chronic condition or conditions, and reduce 30-day readmission rates and ED utilization. Patients with a chronic condition are also eligible for the innovative Women’s Health CHW program; information about that program will be provided in the next section.

In response to the 2019 CHNA’s identification of food insecurity as a significant need in the community, ChristianaCare created two new food insecurity programs that address chronic conditions and social determinants of health: the Delaware Food Farmacy and Produce Delivery. In partnership with community-based organization Lutheran Community Services, ChristianaCare developed the Delaware Food Farmacy (DFF). The DFF, launched in February 2021, is a 6-month nutrition based comprehensive care intervention with food provisions. It is specifically designed to help Medicaid primary care patients with uncontrolled diabetes, hypertension and/or heart failure self-manage their chronic condition through a comprehensive care model, treating the “whole” person. The program objective is to improve patients’ chronic conditions through medication reconciliation and adherence, chronic disease self-management and monitoring (BP, A1c, weight), provisions of foods necessary for chronic disease management,