Spotlight on Population Health
We caught up with Becky Betts, RN and manager of Population Health to get up to speed on what's happening with community outreach, COVID-19 and to see how things are going since their launch in 2019. Population Health is a new service line dedicated to maximizing health outcomes for individuals and communities through the design, delivery and coordination of affordable quality health care.
Foundation: It's been quite a journey, Becky, since your department launched last year. What led to its launch?
Becky: The Providence system started a journey a few years ago towards Health 2.0 which is a bold vision and direction to enhance wellness, prevent illness and strengthen community self-care. It's a 'strategic roadmap' that will move us from a primary emphasis of caring for ill and injured individuals who seek our care, to partnering with communities to co-manage health and create wellness. It means getting outside of our walls.
Locally, our response was to launch the population health service line last year. We were fortunate to have received two years of funding from the Greater Columbia Accountable Community of Health (GCACH) to get started. This created a foundation to explore community needs, close care gaps and identify opportunities to launch programs. Two key priority programs were identified: launch a Community Health Worker (CHW) program and launch a comprehensive Behavioral Health program.
Foundation: How many people are on your team now and what areas have they been focusing on?
Becky: Well, I refer to our work as "pre-COVID" and "post-COVID"! The Population Health team is comprised of three RN Case Managers, a heart failure navigator, a social worker, a part-time pharmacist, and we've recently hired two community health workers (CHW) in direct response to the increased urgency in our work.
Our team works closely with our most medically and socially complex patients. Often, they struggle with congestive heart failure, diabetes, asthma or mental illness (and sometimes far more than one of these) along with lack of housing, food, transportation and other basic resources. It's difficult to manage heart disease while you are living under a tent and do not have a way to get to our doctor appointments. But this is the reality for too many people in our community. We host weekly 'Community Case Conferencing' which brings different agencies together depending on the needs of our most vulnerable patients. Representation included EMS, law enforcement, Comprehensive Healthcare, Waypoint, Family Medical Center, Walla Walla Clinic and BMAC’s youth engagement team.
Foundation: How has COVID-19 changed your world?
Becky: We've had to immediately pivot and respond to the crisis. Our partnership with the Department of Community Health has been strengthend through the pandemic. Our team is providing medical case management, rounding and wellness checks at homeless shelters. We are also partnering on the county’s quarantine and isolation emergency response. We are notifying and doing daily outreach to all COVID-19 positive subjects. About half are Spanish speaking and having access to our bilingual nurse has been a game changer. What a comfort to have this level of support in your native language! We have assisted with contact tracing, using EPIC and our analytics to track down positive subjects. The work we are doing has recently been referred to as "best practice" and should be modeled in other counties!
We are maintaining a COVID outreach registry, which has amassed 1500 names and growing. All day we hear the despair, fear, depression and anxiety in patient’s voices. What started out as a symptom triage phone outreach program, has quickly morphed to a mental health and wellness check. Through the Arts & Health program, we're able to offer them a kit of art supplies to provide hope and a welcome distraction. We are helping our community navigate these difficult times.
Foundation: What keeps you up at night?
Becky: COVID-19 has increased the urgency of our work and the overall need because of the number of patients in need is increasing every single day. We had planned to launch our Community Health Worker program after receiving Foundation funds but there was no time to wait. We've hired two amazing individuals who will be starting soon but that means other crucial projects such as our Behavioral Health Integration and, because of other increased costs, hiring an additional two Community Health workers will be shorted resources. And we know that mental health needs are growing exponentially by the day amidst COVID. We are so 'in the work' right now, I havent thought about the long-term budget ramifications but some programs will need to be placed on hold until we secure funding.
Foundation: What's next for you and your team?
Becky: My team is amazing and we are ready for whatever comes next. Our goal is to be responsive to community needs. We have launched a COVID Coaching Hotline for patients who are pending results or are positive. They can connect with us if they have any concerns or questions. We are also helping our non-profit partners and their clients with medication access and navigation. We recently coordinated the COVID-19 testing of a large employer in our area and, after discovering that many middle and high school students are going hungry over the weekend, we partnered with Lincoln High School to do a meal, snack and toiletry pickup. We are so thankful the Foundation received a generous gift from Dr. Chris and Chandra Hall coupled with other restricted funds to cover the costs. I firmly believe in our mission of serving the poor and vulnerable and creating a healthier world as a result. I am called to this work and know that we will look back on this time
The Community Health Worker program is a fundraising priority for Providence St. Mary Foundation. If you're interested in learning more about the needs of Population Health, please contact us at PSMFoundation@providence.org or (509) 897-2091.
Population Health Nurse Sherri Lynn handing out masks to an unsheltered individual
Sherri Lynn, RN (Population Health), and Sarah Murray, RN (Department of Community Health)
Population Health nurses Kristy and Sherri Lynn bringing food to The Loft for middle and high school students
After a long day at Tyson Foods