Population Health
CCHS Population Health connects patients with programs and support based on their individual needs. Our team works across CCHS departments and with community partners to help coordinate care, connect patients with resources, and provide ongoing support.
Patients may participate in more than one Population Health program as their needs change.
Community Health Workers
Our Community Health Workers help identify patient needs and connect people with the right Population Health services and resources.
Patients may be referred by a CCHS provider, another department, or a community organization. When appropriate, our team can meet with patients in their homes to better understand their needs and coordinate support.
Health Guide Program
Support built around what matters to you
Managing your health can come with a lot of questions. Sometimes it helps to have someone you can talk things through with.
The Health Guide Program offers personalized support based on what matters to you. A Health Guide can help you better understand your health, talk through questions, find useful information, and work toward goals you choose.
Support may include:
- Understanding a health condition
- Nutrition and physical activity
- Stress and coping
- Talking with your healthcare providers
- Finding helpful information and resources
- Setting personal health goals
You choose where to start
Your Health Guide is there to support you, not lecture you or tell you what you should be doing.
The conversation is guided by your questions, your goals, and the areas where you would like more support.
Patients may be asked to complete a short survey about how comfortable and confident they feel managing their health and working with their healthcare team. There are no right or wrong answers.
Your responses help our team better understand what type of information or support may be most useful to you.
If you indicate that you would like additional support, a member of the Population Health team may contact you with more information.
The survey may be repeated in about three months to help us understand whether your confidence or support needs have changed.
Interested in learning more?
Call 509-540-8122.
Meet the Population Health Team
Our Population Health team helps connect patients with support, resources, and programs based on their individual needs. Recognized as 2024 Rural Health Heros of Washington by the State Office of Rural Health.
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.
Our Palliative Care initiative
Palliative care, pronounced pal-lee-uh-tiv, is specialized care for people living with serious illness.
It focuses on relief from the symptoms and stress of illness, with the goal of improving and maintaining quality of life for both the patient and family.
Palliative care can be appropriate at any age and at any stage of a serious illness and may be provided alongside active treatment.
The palliative care team helps patients and families understand their illness, consider their options, and make informed decisions about care.
Palliative Care Road Map
Patients and families can download the Washington State Palliative Care Road Map for additional information.
https://waportal.org/sites/default/files/documents/P-careRoadmap.pdf
For more information about Washington State's Palliative Care initiative: Washington Rural Palliative Care Initiative(opens in new tab)
Foot Care Clinic
Day: Thursday only
Eligibility: Ages 60+
📍 Location
535 Cameron Street, Dayton
🗓️ Appointments
Approximately every 10 weeks
💲 Cost
No charge for services
Donations welcome to help cover wages and supplies not fully funded by the state grant
Everyone is welcome here. We are committed to providing compassionate, respectful care to every person we serve.
🩺 Care Provided By
Registered Nurses (RNs)
This program is made possible through a foundational grant by the ALTC. Learn more at https://www.altcwashington.com/
