The evolution of health care management as a critical primary health care service in Rutland County has shown how prevention has become a key opportunity to improve outcomes. While this may seem obvious, the complexity and cost of providing health care overshadows the importance of prevention. Care Management is a service that can address the need for increased focus on prevention through patient education, recognition of the social determinants of health, and addressing complex care needs with preventive programs that have the potential to prevent future health problems.

As Director of Community Health and Quality, education, communication and prevention have become my top priorities at Community Health.

In Vermont, we are committed to making healthcare accessible to everyone. The state’s Accountable Care Organization (ACO), OneCare, supports a federally funded cost-based model.

Values-Based Care encourages and rewards our primary health care mission of providing quality care in the form of treatment, early intervention and prevention to reduce healthcare costs. The Rutland Region Health Assessment, completed in 2021, identifies social determinants such as access to food, housing and transportation as having a significant impact on future health problems. The report also focuses on conditions such as diabetes and risk groups such as those over 65 years of age.

At Community Health, we have identified several priority prevention programs as the basis for creating clinical responses to the prevailing problems in the region, which were noted in the health assessment. Here are the three programs we currently focus on:

– annual Medicare wellness visits,

— Sepsis/UTI awareness,

– Education for prediabetes/diabetes.

The Medicare Annual Medical Visit (MAWV) is a free service offered by Medicare that focuses on prevention and is designed to keep people healthy, reduce the risk of disease and injury, and provide the support needed for a healthy quality of life. The purpose of MAWV is to check the health status of a person and develop an individual prevention plan. Medicare covers one free wellness center visit each year for those enrolled in Medicare Part B for at least 12 months. There is no co-payment or deductible to visit.

Sepsis, the third leading cause of death in the US, is a life-threatening condition caused by the body’s response to infection. Urinary tract infections (UTIs) are common infections that are preventable in most cases. If ignored or left untreated, a UTI can lead to sepsis. A UTI is one of the most common emergency department illnesses in Rutland County.

Diabetes, a condition that occurs when blood sugar or blood glucose levels are too high, has been identified in the Public Health Assessment as affecting 13% of Rutland County’s population. Community Health maintains an ongoing certified diabetes education program for people with diabetes. Our focus has shifted to educating and informing the public about diabetes prevention by identifying individuals at risk of developing diabetes and educating about the signs of prediabetes.

Education, training and the use of technology are ways Community Health is improving the delivery of preventive services. Access to data on care and outcomes has helped identify gaps in care and determine where preventive services will have the greatest impact.

According to the National Library of Medicine, “The Affordable Care Act (ACA) has resulted in several key policy changes that encourage both patients and healthcare providers to become more involved in preventive care. For patients, the ACA has eliminated cost-sharing across a wide range of primary and secondary prevention services and introduced preventive Medicare Annual Medical Visits (MAWVs).” According to the government, ACOs are “increasingly interested in providing preventive services.”

By sharing data and our approach to preventive care with healthcare providers, we have been able to improve the effectiveness of preventive services and encourage value-based care with an added focus on quality improvement, while delivering the highest levels of care to improve outcomes. .

Andrea Wicher is Director of Public Health, Population Health and Quality. Community Health is Vermont’s largest federally qualified medical center, a network of primary care, pediatrics, mental health, dental and pharmaceutical services with offices in Rutland, Brandon, Castleton, West Flight and Shoreham.

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