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Leveraging Community Health Workers within an Interdisciplinary Care Team to Care For Older Adults

BY LAUREN O’CONNELL, LICSW, AND ROBERTA CAPP, MD, MHS Community health workers (CHWs) are non-clinical members of the community who usually share ethnicity, language and life experiences with the community members they serve (NIHLBI, 2023). Traditionally, CHWs are social and change agents; they reduce disparities and inequities by expanding knowledge and access to benefits and community services. […]

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CalAIM — A Lesson in Transition

BY SUSANE HAO, RN, MSN, CLCP, AND THERESA HERNANDEZ, CCM Healthcare providers and case managers encounter patients who experience a combination of barriers related to social determinants of health (SDoH) that make it difficult for patients to manage their chronic medical conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes mellitus, hyperlipidemia, hypertension

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Viewing Mental Health Parity from a Population Health Perspective

BY GARRY CARNEAL, JD, MA, JACK SHOEMAKER, MS, AND TOM WILSON, PhD Treating diseases of the brain is as important as treating any physical condition. Yet, U.S. health insurers have earned the dubious reputation of not covering behavioral health conditions (“BH,” aka mental health and substance use disorders) adequately when compared to physical health conditions (“PH,” aka medical/surgical care). From a population

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Case Management Leads the Team in Transitions with Patients with Substance Abuse Disorder and Infective Endocarditis

BY BETSY STOVSKY, RN, MSN, AND MARY McLAUGHLIN DAVIS, DNP, NEA-BC, ACNS-BC, CCM Patients with infective endocarditis (IE) due to opioid substance use disorder (SUD) and injection drug use (IDU) present to the acute care setting with a myriad of surgical, medical, psychiatric and social problems. The complexity of this patient population requires an experienced team of

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The Journey from Public Health to Re-Emerging and Reigniting Population Health

BY JENNY QUIGLEY-STICKNEY, MSN, RN, MHA, MA, CCM, ACM-RN, CMAC, CPHM, FCM Over the last three years of the COVID-19 pandemic, many healthcare providers have confused public health and population healthcare specializations. Both concepts are equally important to the field of case management but take different approaches to how to heal the wounds of a nation.

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When Population Health Outcomes Are Not Reported — Toot Your Own Horn!

BY KELVA EDMUNDS-WALLER, DNP, RN, CCM “In God we trust, all others bring data.” — W. Edwards Deming Some leaders need help implementing case management services in primary care settings. The benefit of case management to patients, providers and primary care teams is enormous, so it is unfortunate when implementation is unsuccessful. Multiple factors influence case

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