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Wabanaki Public Health

Wabanaki Public Health. Patient Navigation Model Blood Pressure & Cholesterol Pilot. 5 Tribal Health Centers. Micmac Service Unit Penobscot Nation Health Center Maliseet Health and Wellness Center Pleasant Point Health Center Passamaquoddy Health Center at Indian Township .

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Wabanaki Public Health

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  1. Wabanaki Public Health Patient Navigation Model Blood Pressure & Cholesterol Pilot

  2. 5 Tribal Health Centers • Micmac Service Unit • Penobscot Nation Health Center • Maliseet Health and Wellness Center • Pleasant Point Health Center • Passamaquoddy Health Center at Indian Township

  3. Tribal Health Center Resources • PCP • RN • Pharmacist (Pleasant Point, Penobscot, Indian Township) • Community Health Resource (CHR) • Registered Dietician(PPHC, PHC, PNHC, MHWC) • Fitness Coordinator • Clinic Manager and Staff

  4. Facilitation of trainings • Master Blood Pressure trainings - QI • Providers re: the importance of accurate measurement for prescribing • Clinical staff • CHR’s • Cholesterol Screening in Community • Clinical staff • CHR’s

  5. Priority Population • Each clinic will identify 10 priority or at risk clients who will have in home blood pressure and cholesterol screenings. • Criteria to be determined by Health Directors Examples : • diagnosed with Hypertension or be at risk for • diagnosis of Diabetes mellitus • history of smoking

  6. Screening • CHR’s or Clinical staff will go out into the community to do in home screening for identified individuals. • Education regarding numbers as well as tools and resources will be provided. • Results shared with Clinic

  7. Next Steps – engaging patient • Structured follow up mechanism • RN provided results, identify need for visit • Referral to RD for education as needed • Referral to Fitness Coordinator as needed • Pharmacist • Follow up call to patient along with education PRN • Pharmacy will notify provider if missed refills

  8. FOLLOW UP The method of follow up will depend on individual outcomes Follow up will include: • Phone calls from CHR, RN, RD, Pharmacists • Reminder cards • Emails

  9. Goals • Use of evidence based guidelines • Establish a structured follow up model to monitor patients progress and schedule visits as needed • Engage patients in their care

  10. Disclaimer Slide NO CONFLICTS OF INTEREST OR COMMERCIAL INTEREST INVOLVED IN THIS PROJECT

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