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Improve Diabetes and Hypertension Control for Patients Experiencing Homelessness. Why this is important Among our patients engaged in primary care, patients experiencing
homelessness have higher rates of uncontrolled diabetes and hypertension, which can be treated. Our patients experiencing homelessness also have higher rates of visits to the emergency room and inpatient stays. We need to improve the overall health of this population.
How we will do it We will invest additional resources to support the care of our patients experiencing homelessness through specialized clinical models in primary care that provide both medical care and social support, as well as more flexibility and walk-in appointments. Our patients experiencing homelessness will be partnered with community health workers who will help them to meet patient-centered goals, which may include improving engagement with their medical & behavioral health teams, reducing use of substances that exacerbate these conditions, or progressing on their journey toward permanent housing. We will embed resource navigators in the emergency room setting that will help patients experiencing homelessness navigate the complex medical and social system. How we will measure success We will monitor metrics of Diabetes and Hypertension control in our patients experiencing homelessness that are seen in primary care. We will also monitor the number of emergency room visits and inpatient stays for our patients experiencing homelessness. Check out next week’s INSIDER to read about goals 6 through 10. More to come!
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