Health Need #4: Diabetes Anticipated Impact
Health Need #5: Healthcare access Anticipated Impact Improved access for vulnerable populations
Specific Actions to Achieve Impact Diabetes Self-Management Program for patients to benefit from education, exercise, nutrition and support - Promote cutting-edge programming that includes exercise during curriculum delivery
VVH Resources
Partnering Organization(s)
Specific Actions to Achieve Impact - Implement AHCM social determinant survey in both inpatient and outpatient care settings to provide a more robust picture of the many factors that influence an individual’s overall wellness - Implement inpatient care coordination program to identify vulnerable patients, conduct assessment, make effective referrals and connect them to community resources - Implement Emergency Department post-discharge follow-up appointment scheduling - Offer care coordination for identified Emergency Department high utilization patients including with all Valley View primary care practices - Implement comprehensive medication management with integrated clinical pharmacist for ambulatory setting - Explore nurse (RN) home visit program for high risk inpatients
VVH Resources Staff time
Partnering Organization(s) Care Transition Collaborative Community Care Alliance EMS providers Mountain Family Health Center Quality Health Network Rocky Mountain Prime West Mountain Regional Health Alliance Valley Health Alliance
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