Achievement Awards Spotlight: Independence Health System Clarion Hospital

June 28, 2024

HAP's annual Achievement Awards honor hospitals and health systems for their innovation, creativity, and commitment to patient care. The Achievement Awards showcase and share member hospitals’ and health systems’ successful programs and best practices.

This year, Independence Health System Clarion Hospital won the Community Champions Award for its Care Coordination Implementation project.

Here’s what you need to know:

• The challenge:  The hospital made it a priority to transition from “illness care” to “wellness care,” focusing on prevention, education, and care coordination for its rural community.
  • A recently completed community health needs assessment helped provide the foundation and impetus to develop the program.
• Taking action:  With the hiring of a care transition navigator, the hospital launched its Care Coordination Program focused on supporting those with diagnoses of diabetes, congestive heart failure, and other respiratory needs.
  • The program included new screening and an integrated registry to track and manage patients through electronic medical records.
  • All admitted patients that have a diagnosis of chronic obstructive pulmonary disease (COPD), pneumonia (PN) or were high risk are contacted within the first seven days of discharge and asked questions related to their health-related screening needs. They also receive follow ups at 30, 60, and 90 days.
• Results:  The program tracked admissions and noted a reduction across key groups and for all 30-day readmissions, as well as a reduction in total cost of care.
• Next steps:  The hospital plans to take its lessons learned and continue to expand and adapt the process to patients with other diagnoses and meet patients at their point of entry, including the emergency department and physician offices.
  • Adding the care transition navigator also has facilitated other community partnerships and opportunities to address social determinants of health (food insecurity, education, economic stability, etc.).
• Quotable:  “Organizations interested in beginning a care coordination program should first evaluate their community health needs assessment to identify the greatest areas of need as well as resources in the community,” the team noted in its entry. “Early in planning, information technology staff should be utilized to assist in the development of a tool to gather information on the potential patient for inclusion and assist in the documentation of follow-up.”

Congratulations to Independence Health System Clarion Hospital for its outstanding initiative to support care in its community. Learn more about the project online.

Questions about the HAP Achievement Awards may be directed to HAP Member Services at (717) 561-5359.