Published on November 19, 2020

Fisher-Titus receives Population Health Pioneer Award from Caravan Health

Fisher-Titus has received the “Leadership in Care Coordination” Population Health Pioneer Award from Caravan Health for their work to increase enrollment in the Chronic Care Management program.

“We are proud to receive this award from Caravan Health,” said Dr. Brent Burkey, president and CEO of Fisher-Titus. “The Leadership in Care Coordination award is a testament to the hard work our chronic care navigators have put in to support patients with chronic illness in our community.”

The Population Health Pioneer Awards are presented to Caravan Health’s partners who have best served their patients, community, and the health care industry through their leadership, dedication, and innovation over the past year. The awards highlight nominees who incorporated innovative approaches to care during the COVID-19 pandemic and demonstrated a commitment to diversity, equity, and inclusion in the workplace and the communities they serve.

“This award highlights all the great work our team does to manage our patients and their chronic illnesses,” said Karen Dickinson, vice president, quality & clinical resource management. “The program has a huge impact on our patients and we get to see firsthand how it improves the lives of the patients we touch.”

Over the past year, Fisher-Titus increased their chronic care management enrollment from 5% of patients to 19.9% meaning they are working with more individuals in the community.

Chronic care management helps patients control chronic illnesses by having chronic care navigators reach out them to discuss health care needs and concerns monthly. Chronic care management helps patients stay out of the emergency room, prevents hospital readmissions, and increases their overall quality of life.

Chronic care management services include at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month. Patients in the program have multiple (two or more) chronic conditions expected to last at least 12 months that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. The chronic care navigators work with these patients to establish, implement, revise, and monitor a comprehensive care plan.

“As we look at the future of the program, we are excited about our strategic plan,” said Dickinson. “Looking ahead, we are working toward a multidisciplinary approach to chronic care management. We are looking to include a pharmacist, social worker, and dietician on our chronic care management team and incorporate a fitness program for certain populations.”

The Fisher-Titus Chronic Care Management team includes chronic care navigators, Sharon McGrail, Paul Young, Bettie Whitright, Sandy Fleming, and Rebecca Spettle.

For more information about chronic care management, talk to your primary care provider. To find a primary care provider near you, visit