SNMH Community Grants |

SNMH Community Grants

SNMH Foundation Executive Director Kimberly Parker (second from left) presents a check to representatives from FREED, Western Sierra Medical Clinic and CoRR on behalf of the Dignity Health Community Grants Program.
Submitted photo |

Improving the health and wellness of our community takes the efforts and resources of many organizations and individuals. For that reason, Dignity Health Sierra Nevada Memorial Hospital (SNMH) Community Grants Program recently awarded its 2016 grant to a collaboration of three local nonprofits serving the medically at-risk in western Nevada County.

The grant supports streamlining access to medical and social services for the at-risk population in our community. Funds were distributed among three organizations: The FREED Center for Independent Living, which will act as the fiscal agent, received $42,000. Community Recovery Resources (CoRR) received $10,508 and Western Sierra Medical Center (WSMC) received $10,000.

This marks the third year that a collaborative grant has been provided to these organizations.

“We have seen the tremendous value in their programs over the last several years, and we are pleased to fund this collaborative once again,” said SNMH Community Benefit Specialist Stephanie Kreiter.

The grant brought together three distinct organizations with varying purposes: FREED works to promote independent living for those with disabilities; CoRR’s programs focus on helping those with substance abuse and/or behavioral health issues; and WSMC provides medical, dental and behavioral health-care services.

According to Ana Acton, executive director of FREED, the grant supports two programs — Care Transitions Intervention and Patient Navigation — which each aim to connect community members with a primary care provider and other support services.

As our community moves from the traditional rural health model focused on acute care, to a more holistic approach, the health of the entire person must be addressed, Acton shared.

This means meeting not only a patient’s medical needs, but also necessary social services as well, such as housing, transportation, caregiver or in-home supportive services, substance abuse or behavioral health services, among a host of other services.

“There’s a strong correlation between connecting these populations with social services and improving health outcomes,” said Acton.

The Patient Navigation program is designed to help connect people with the services they need in order to avoid unnecessary hospital readmission.

Navigators from each organization help individuals identify a primary care physician, fill out paperwork, or connect with substance abuse, disability, aging, and other community-based services.

The organizations provide a warm hand-off, with a staff member personally ensuring that the person is connected to someone providing a needed service, as opposed to simply providing a phone number. This can also help speed the time it takes to receive medical or other care.

“MediCal patients were waiting up to six weeks to get an appointment with a primary care doctor. This program has decreased that wait to one or two weeks. Some patients are even seen the next day,” Acton said.

Another important component of the grant is the Care Transitions Intervention (CTI) program. Patients who agree to be part of the program receive a home visit after they have been discharged from the hospital. Over the course of 30 days, they receive coaching to help them manage their medical condition more effectively, including how to best manage their medications, identify red flags within their health care, and organize their personal health records.

In the past year, the hospital referred an average of 25 patients a month to the program.

“We are able to track hospital readmission rates and we found there’s a clear indication that the work we do actually reduces hospital readmissions,” Acton said.

This year, the plan is to expand the Patient Navigation and CTI services to the SNMH Emergency Department to help connect individuals with the most appropriate health care and follow up services while easing congestion in the Emergency Department.

“These grants are important because they provide much needed funds to our amazing local nonprofit community partners, allowing them to further their efforts and provide excellent services,” Kreiter said. “The support of these services in turn develops the best network of care possible for our patients in the community once they leave the hospital.”

All physicians providing care for patients at SNMH are members of the medical staff and are independent practitioners, not employees of the hospital.

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