Engaging Patients and Providers in Partnership to Prevent Heart Disease "The Middlesex 4P Program"

The Middlesex County Coalition on Community Wellness is announcing a grant award from the State Department of Public Health, Heart Disease and Stroke Prevention Program for a Self-Blood Pressure Monitoring Program. This six month project will end in August of this year. Community Health Center, Inc. (CHC), Middlesex Hospital, the Chatham Health District, and members of the Coalition, have partnered in this project to improve care coordination through blood pressure monitoring in hypertensive patients. Building upon a 2011 federal HRSA-funded hypertension self-management project, CHC and Middlesex Hospital will collaborate to further develop and finalize the model/protocol and update the existing policy for care coordination and self-blood pressure monitoring. CHC’s Registered Nurse, Quality Improvement Manager, will train three Registered Nurses to become nurse care coordinators (NCCs) from Middlesex Hospital Homecare, Middlesex Hospital Center for Chronic Care Management and the Community Health Center. These NCCs will act as intermediaries between clinicians and patients, providing real-time disease management, medication adjustment, and care coordination. Additionally, patients will be trained to utilize monitoring equipment and record results. Self-management emphasizing patient empowerment, goal setting, and problem-solving skills will be provided. Dr. Daren Anderson, VP/Chief Quality Officer for Community Health Center, Inc. and Dr. Alan Douglass, Director, Family Medicine Residency Program will serve as Co-Project Directors. Their existing working relationship, identical electronic health record system, and similar model and infrastructure lay the foundation for a cohesive partnership. Dr. Anderson’s work is primarily focused on quality improvement using data to drive improvement and systems change. Dr. Douglass directs Middlesex Hospital’s Family Medicine Residency Program and associated Family Practice Group with offices in Middletown, Portland, and East Hampton. Middlesex Hospital’s Homecare, Center for Chronic Care Management, Family Medicine Residency and Community Benefit departments will also participate in the project. Chatham Health District will serve as fiduciary; provide project management, and community engagement and education. We are pleased to be partnering with Omron Healthcare® who is participating by donating product to the initiative. Please contact the Middlesex County Coalition on Community Wellness for further information. Thad King; Co-Chair Director of Health Chatham Health District 240 Middletown Avenue East Hampton, CT 06424 (860) 365-0884 Catherine Rees; Co-Chair Manager, Community Benefit Middlesex Hospital 28 Crescent Street Middletown, CT 06457 (860) 358-3034


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