TMC is the community’s leader in chronic disease management: Last year, TMC served more than 78,000 patients who used TMC as their health home for management of their chronic illnesses and general healthcare.
In 2012, TMC was recognized for its rigorous exploration and adaptation of chronic care initiatives when it received a $4.5 million Health Care Innovation Award from the Center for Medicare and Medicaid Innovation via a subcontract with the Rutgers University Center for State Health Policy. This work builds on numerous successful TMC initiatives and the work of the Camden Coalition that employed care management and/or disease management of various high utilizer subgroups in recent years. Over the last 18 months, TMC has rapidly advanced its innovative care management strategy for high-cost, high-need individuals with difficult life situations and complex medical conditions who live in zip codes within the TMC catchment area in Kansas City, MO.
An example of a patient graduate of this innovative program:
“Jim” is a 63 year old African American diagnosed with hypertension, asthma, anti-social personality disorder, bi-polar disorder and anxiety. He has a history of substance abuse and of trauma related to a gunshot wound. He was estranged from his family and lived in a shelter.
The team, which includes a Psychologist, quickly established rapport with the patient. While the Health Coach worked with him on clinical issues, the social worker assisted him in securing housing and re-establishing a relationship with his daughter. The Community Client Liaison and Community Health Advocate provided social support. All members of the team were available to Jim by phone and in person to listen and offer support and encouragement when he expressed frustration and discouragement. He was open to change and worked productively with the team. The patient now takes initiative for his own care and continues to work with the Psychologist. He is drug and tobacco free. Jim was in the program 241 days from enrollment to graduation. Since his enrollment more than 241 days ago, he has not incurred any inpatient admissions or ER visits because he has gained control of his health, with the help of TMC.
Photo, above: First graduating class of the Health Care Innovation Award Program on May 28, 2014.