From staff reports
Clarion Hospital, part of Independence Health System (IHS), was recognized by the Hospital and Health system Association of Pa. (HAP) for implementing a care coordination program to address the needs of patients experiencing chronic health conditions, such as COPD, pneumonia, congestive heart failure, diabetes, and individuals determined to be at higher risk of hospital readmission.
Clarion Hospital’s initiative was one of 13 recognized by The HAP through its Achievement Awards. Started in 1978, the pro-gram recognizes hospitals and health systems that are taking innovative approaches to strengthening the safety and quality of care, enhancing operations and patients’ experience, and partnering with their communities to address public health needs.
In 2021, Clarion Hospital established a care coordinator program focused on prevention, education, and coordination of care. The program aims to assist patients experiencing chronic health conditions navigate a number of health-related and social needs. When admitted to the hospital, patients complete an assessment form identifying their individual support requirements. Patients with chronic health conditions are often at high risk of rehospitalization, so Clarion Hospital assigns a Care Transition
Navigator to work with them upon discharge. The care navigator may assist patients by scheduling follow-up appointments, coordinating transportation, or providing community resources to individuals needing food, disability, housing, or energy assistance. The care navigator contacts patients seven days after being discharged from the hospital, then again at 30, 60, and 90 days to check in and provide additional support as needed.
Since its inception, rates of hospital readmissions of patients experiencing chronic health conditions have gradually declined, along with the total cost of care. The care coordinators have assisted 415 patients since the program was implemented and have expanded their resources to include the newly added Food Institute and Lifestyle Coaching programs located at the Health & Wellness Center.
Clarion Hospital competed against organizations of a similar size for the Community Champions Award, which celebrates hospitals’ and health systems’ efforts to improve community health and access to care, advance health equity, and advocate for the health care community and patients. In total, there were 93 entries for this year’s Achievement Awards.
HAP President and CEO, Nicole Stallings said, “We are proud to announce the winner of HAP’s Achievement Awards, showcasing innovative, patient-centered projects that are making a difference in Pa. Strong health systems make strong communities, and hospitals are central to our shared mission for a healthy Pa.”