UPMC Western Maryland — Cumberland, MD
IMPROVING DIABETES CARE FOR UNDERSERVED COMMUNITIES IN CUMBERLAND, MD
UPMC Western Maryland aims to transform primary care for low-income, rural populations with diabetes who often face geographic barriers to care.
To reach this population, the program embeds diabetes care managers in primary care practices. The program also involves community paramedics who conduct home visits, uses telemonitoring to promote communication between vulnerable patients and care providers, and offers education on diabetes self-management that is culturally appropriate. The organization fosters community partnerships to facilitate access to healthy food and provides referrals to local resources that can address needs related to housing, health insurance coverage, or transportation.
STRENGTHEN PRIMARY CARE & BUILD SUSTAINABLE PARTNERSHIPS
OUR INTERVENTION APPROACH
Improve access to diabetes self-management education and tools for patients and families in three pilot clinics. Identify strategies to advance population health efforts.
- Building upon three years of clinical experience and strong data analytics, expand efforts to work with new intersectoral partners to identify effective strategies
- Utilize existing relationships with over 1000 individuals and groups who have visited or studied the UPMC Western Maryland’s Center for Clinical Resources to disseminate outcomes
Improve access and outcomes for vulnerable individuals with type 2 diabetes and related comorbidities within the UPMC Western Maryland Service Area of Allegany County, Maryland, and the surrounding area
- Address geographic and economic disparities through pop-up clinics, home visits, screening for social determinants, and partnerships that support food security and culturally tailored disease self-management
- Transform primary care practices to improve quality of care for individuals with type 2 diabetes through the addition of embedded diabetes care managers utilizing risk stratification and telemonitoring technology
Enhance sustainability of partnerships by utilizing collaborative intersectoral interventions to reduce disparities and improve patient outcomes
- Engage multi-level teams including non-clinical and community partners to engage vulnerable populations in best practices to address social determinants and improve the health delivery system
UPMC-Western Maryland is focused on supporting unmet medical and social needs:
- UPMC-Western Maryland established the Center for Clinical Resources to be a source of support for patients managing chronic medical conditions such as diabetes, heart failure, and lung disease, or taking anticoagulation medication. Their goal is to effectively co-manage at-risk patients who have a chronic disease in an outpatient setting to improve their health through a focus on unmet medical and social needs through the efforts of a care team made up of community health workers, diabetes care coordinators, and diabetes care and education specialists.
- Food Farmacy (FF) is health-system supported food access program. FF was developed in response to observed food insecurity among complex patients with chronic conditions (e.g., diabetes, COPD, CHF) with the recognition that health outcomes for these patients could improve with consistent access to healthy food. The program is a partnership between the hospital and food vendor Aramark, with weekly food distribution at no cost to the patient. A registered dietitian provides disease-specific, culturally relevant education. Food boxes include recipes and food tailored for the nutritional needs of patients and their chronic conditions, and includes fresh produce, lean proteins, and whole grains.
Jo M. Wilson, MBA, FACHE
Vice President of Population Health
Jo M. Wilson, MBA, FACHE, is Vice President, Population Health for the UPMC Western Maryland in Cumberland, Maryland. She joined UPMC Western Maryland in September 2003 as the System Director of Radiology and was named Vice President, Ancillary Support Operations, in 2006.
As UPMC Western Maryland, previously Western Maryland Health System, transitioned to value-based care in 2011, Wilson became involved with the logistics associated with transforming care delivery to improve patient outcomes and reduce unnecessary admissions. She developed a successful, award-winning model for chronic disease management and oversees the health system’s population health efforts, including telemonitoring.
Wilson is a graduate of Towson State University and obtained her MBA from Loyola College. She completed a fellowship in healthcare at the Kellogg Graduate School at Northwestern University and a certificate in the business of medicine at Johns Hopkins University. Jo is a Fellow of the American College of Health Care Executives and is board certified in healthcare management.