Improving Chronic Disease Management for Underserved Populations: The Core Health Program Triple Aim Initiative

Abstract

Core Health Program Triple Aim Initiative A review of the initiative: 12-month managed care program for underserved individuals diagnosed with heart failure and diabetes According to Raghupathi and Raghupathi (2018), the level of chronic diseases among Americans continues to register an upward trend while the cost of accessing affordable healthcare facilities with quality services remains a misery. Fawcett et al. (2018) add that America lacks effective and efficient chronic disease management programs targeting underserved populations. Such limitations are a significant concern following the disproportionate representation of chronic diseases among challenged persons. Paying close attention to congestive heart failure (CHF) and diabetes as the two primary chronic conditions that claim most lives in Michigan; calls for an effective community-based program to enhance the management of such conditions and lower morbidity rates. As noted, chronic conditions often require check-ups and hospitalization, which remains challenging for financially disadvantaged persons, citing America's high cost of living. Such a program will be a great relief as it will cater to recurrent hospitalizations for such patients helping them adhere to treatment plans and get knowledge about their conditions, enhancing management of such conditions in the long run. Spectrum Health care came as a rescue by implementing the Core Health Program in 2009 aimed at enhancing the management of Chronic Heart Conditions and Diabetes. It is a program that reaches underserved people whose economic, cultural, demographics, and language characteristics hinder their access to quality health care, increasing chances of adverse health outcomes. A registered nurse-led core health team included nurses and community health workers. The group offered education through home visits ranging from 2 to 8 weeks based on the target patients’ unique needs. The central area of concern was offering insights on the nature of patient's conditions to make them understand how to manage their health conditions, offer insights on how to work with the health care system, improvement of patients' health through lifestyle changes, connecting with community resource and establishment of personal health goals culturally relevant and sensitive. The team provided written materials on medication use and adherence, exercise/fitness, and the significance of proper diet in managing both chronic conditions. Since the program was voluntary and free, it became available for the target patients for 12 months in the comfort of their homes to ensure appropriate self-management skills at the end of the program. According to Kangovi et al. (2017), there is a growing body of evidence supporting the role of community health workers (CHWs) in effectively managing chronic conditions like cancer, asthma, HIV/AIDS, diabetes, and heart problem. Incorporating such a class of professionals enhanced the Core Health Program's effectiveness in managing diabetes and...