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Transition of care manager spearheads population-health efforts

While many health organizations were merely fighting to keep up with the workload in 2020, Norman Regional Health System began to expand its mission to include more areas of population health.

The Norman Regional Health System’s Food Pharmacy, which launched in partnership with the Norman Regional Health Foundation and the Regional Food Bank of Oklahoma in October 2020, was created to address food insecurity and malnourishment among Norman Regional’s acutely ill or vulnerable patients.

But that’s not all.

Kristin O’Neal, RN, Manager of Transitions of Care Coordination, also understood the need for all populations—including at-risk populations—to have the opportunity to be vaccinated for COVID-19, as it is unrealistic to expect some patient groups to come to the health system on their own. So O’Neal began conversations with community partners around setting up small clinics at locations such as homeless shelters, mental-health day centers, disabled/low-income housing, and homeless encampments, ultimately forming teams to vaccinate 280 people in two weeks.

NRC Health recognizes this level of care with its Excellence in Human Understanding Award. This article is one of a series celebrating the achievements of one of our nominees who has a transformative impact on patient care.

Initially, the food pharmacy team provided screenings for food insecurity and gathered data in May 2020. The Food Pharmacy officially launched in October 2020 and, with the help of the entire health system, launched with a system-wide food drive. The team is currently planning to expand the service to the health system’s emergency departments and clinics.

“Every investment we make in our community—it’s not necessarily a dollar sign at the bottom line, but it’s the pride that we give back in making our community a better place to live,” says Donna Avila, RN, Director of Care Coordination at Norman Regional Health System. “It’s about having healthy environments for our children to grow up in and adding populations to hopefully age in place longer, and really knowing that there are good people—that we are all in it for the greater good of our community as a whole.”

The Food Pharmacy team doesn’t just give out food; they also ask for feedback from the recipients to ensure they’re getting what’s best for them. Assessment and thought are put into each patient’s responses to identify which food-compilation efforts will be most appropriate for their medical, environmental, and social needs. During follow-up calls, the team asks several questions, such as:

  • Did you eat the food you received from NRHS?
  • What was most useful from the food provided?
  • Did you like the food?
  • Anything you didn’t like?
  • Was it difficult to prepare (cook/make)?
  • How many people did the food provide for?

While the team acknowledges that this is a short-term solution for patients, their efforts also focus on discussing and coordinating long-term food resources, so that food insecurity does not remain a constant burden.

“Some of the successes we’ve tracked are the number of patients that have had successful SNAP benefits enacted after we’ve connected them, or successful referrals to Meals on Wheels,” O’Neal says. “We looked at their readmission rates for this population, which we know is a vulnerable population, and the readmission rates were significantly lower than for our overall population.”

And the added layer of care coordination didn’t end with food. “We wanted to find out, ‘Have you talked to your primary-care doctor?’ ‘Are you able to make that appointment?’” O’Neal says. “We were able to remove those barriers that we’re used to removing in care coordination, which I think proves how important those questions in our area are to continue our success and the prevention of those readmissions.”

Avila says the increase of coordination for their community would not have happened without strong community relationships that had already been built by the Care Coordination division.

“This would not be possible without that trust and rapport already being fostered,” she says.

“This team daily identifies and intervenes on behalf of our sickest and most challenging patients. They strive to treat the patient as a whole and look at all aspects of the situation—social, psychological, and medical needs. This team does so with an open mind and a kind heart.”