Thriving by Partnering: Care Coordination

Partnerships are the single greatest value to our work. By linking up and working with other stakeholders in the community Mary’s Center is able to improve efficiency and sustainability and strengthen our programs, continuing on with our tradition of providing high quality health and social services to those most vulnerable living throughout the Washington, DC metropolitan region.

Mary’s Center is the proud recipient of a $100,000 grant from Medtronic to support the facilitation of our Care Coordination program. This program aims to improve hypertension, hyperlipidemia and diabetes care for our participants. It targets chronically ill individuals and empowers them to take control of their illnesses through a combination of culturally appropriate self-monitoring, guided support, and education. To implement the program, Mary’s Center will expand our Care Coordination team to include four Clinical Nurse Coordinators, one Life Cycle Health Educator, and one Nutritionist.

When our providers identify a participant with a chronic health condition, they refer the participant to a “health coach” (either a nurse or trained medical assistant) and enroll them in the Care Coordination program. The participant and coach develop an individualized care plan including goals and self-monitoring support, and the participant is provided with a self-monitoring tool for his or her health condition. The participant receives daily text or phone reminders to take his or her medication, and is regularly contacted by the coach to obtain self-monitoring data and discuss goals. During a follow up visit, the participant meets with a Health Educator and a Nutritionist to learn more about disease processes, goal reinforcement, and health eating behaviors.

Care coordination has been identified as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the health care system. With Medtronic’s support, Mary’s Center has dedicated more staff time and resources to this important strategy. To date, more than 85 participants with a hypertension diagnosis have enrolled in our Care Coordination program. Eighty-four percent (84%) of program enrollees have had a decrease in their blood pressure reading since enrolling and 41% have reached the target blood pressure goal, results that speak to Mary’s Center’s and Medtronic’s mutual goal for the partnership – to save lives.


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