Delta Health Systems Implementation Program - Delta Health System Implementation Program WCMH Chronic Care Management and Remote Patient Monitoring Program Washington County Memorial Hospital (WCMH) requests Delta Health Systems Implementation Program funding to implement Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) programs at our rural health clinics. This initiative directly responds to technical assistance recommendations from the Delta Regional Community Health Systems Development program, addressing population health management, patient experience, emergency department utilization, and care quality. Need: Washington County, Missouri ranks among the unhealthiest counties in the state (107/115) with significant challenges: - Higher chronic condition rates (41% obesity, 11% diabetes) - Higher emergency department utilization and preventable hospital stays - Limited primary care access (3,120:1 patient-to-provider ratio vs. 1,420:1 statewide) - Poor health behaviors (28% smoking, 30% physical inactivity) - Lower life expectancy (73.8 years vs. 77.3 statewide) - Rural geography (80.5% rural population) - Socioeconomic challenges (15% uninsured rate) These factors contribute to residents living an average of 7.3 years less than peers elsewhere in the U.S. Project Goals: 1. Deploy chronic care management services at WCMH Rural Health Clinics 2. Implement remote patient monitoring for patients with complex conditions 3. Improve population health quality measures 4. Ensure sustainability through new billing and coding practices Approach: WCMH will partner with a third-party vendor to establish CCM and RPM programs at all rural health clinics. The vendor will handle clinical care management while WCMH manages patient enrollment and billing. The program will start with 100 patients in year one and expand to 250 by year two, including: - Development of care management protocols - Staff training on processes and billing - Patient education - Quality metrics tracking Expected Outcomes: Short-term: Enrollment of 100 patients with 90% receiving monthly CCM contacts. Long-term: - 250 enrolled patients - 10% reduction in ED visits - 15% reduction in readmissions - Improved clinical measures - 20% increase in patient satisfaction - Sustainable revenue stream Population Served: Washington County, Missouri residents with chronic conditions, focusing on Medicare beneficiaries and those with complex health needs requiring ongoing care management, particularly underserved rural residents. Sustainability: By establishing billable CCM and RPM service lines with proper coding and billing procedures, WCMH will create a sustainable model with program revenue expected to exceed costs by at least 15% by the end of the performance period. This project aligns with DSIP objectives by implementing evidence-based practices that will improve healthcare delivery, financial sustainability, and patient outcomes in rural Washington County, directly addressing recommendations from technical assistance consultations.
