Since 2016, CCHS has created diverse programs to assist patients with a wide range of needs. Our coordinated care approach involves close collaboration between CCHS departments and external partners. Patients can transition between programs based on their requirements and may be part of multiple programs simultaneously. Our Team frequently partners with CCHS Transportation for coordinating trips to appointments within or outside of CCHS. Our Population Health Team was recognized as 2024 Rural Health Heros of Washington by the State Office of Rural Health.

Population Health/ CHW: Our entry level of care identifies patients from various CCHS departments, referrals from Providers or local organizations and agencies. Our CHWs and Team meet patients in the home, review information, identify patients’ needs and then we assign programs and Team members to assist with those needs.

Palliative Care: Is for patients with heavy burden of disease who are still pursuing curative or high levels of healthcare and need support. RN’s, CHWs and ARNP help coordinate care and emphasize symptom management. We include care of the whole family, caregivers, pets and those important to our patients. Coordinating care, medications, specialists & agencies can really help ease the burden on patients and families.

Partners Improving Patient Health: Disease management for Heart and Lung diseases helping optimize standards of care, improve patient knowledge and independence, create Action Plans for rapid treatment of worsening status which can prevent needing emergency and hospital care. In home and phone-based support increases rapid access to timely solutions and coordination of care and often work with PT and RT for advanced rehab.

Chronic Care Management: Phone based access to Team RNs and CHW allow better coordination of care and assist patients with monthly check ins or direct phone numbers for patient use. This program often is in conjunction with others to aid in coordination, support documentation and communication for the benefit of enrolled patients. This also allows for CCHS reimbursement of RN care performed outside of the home.

Diabetes Education: RN care for management of diabetes, monitoring and assisting maintain standards for care for Diabetes. RN may help obtain Continuous Glucose Monitors, titrate insulin, coordinate with Providers and specialists and has been shown to greatly decrease patient glucose levels and A1c.