Type of Program
Nutrition Education and Policy, Systems, and Environmental Change
Summary
Community Care Teams (CCTS) are multi-disciplinary, community-based, practice-integrated care management teams that work with Patient Centered Medical Home (PCMH) practices to provide enhanced services for high-needs patients. CCTs are funded as part of the Medicaid (MaineCare) PCMH project. Since 2015, Maine SNAP-Ed has been implementing a Community Care Team (CCT) project in Androscoggin County. Through collaborations with three key partners - Androscoggin Home Care and Hospice, DFD Russell Medical Center and Tri-County Mental Health Services - Nutrition Educators have reached a total of 252 high-risk patients in 2015 and 2016 with nutrition education. Patients and their families learn how to shop, cook, and eat healthy on a limited budget. CCT case managers work with the Nutrition Educators to help reduce barriers to participation by addressing transportation challenges, assisting with outreach and recruitment, and securing appropriate venues for classes. Partnering agencies describe the approach as both applicable and effective for their patients, providing much-needed nutrition education services for low-income Mainers that are frequent users of the health care system.
Challenge
Individuals with high health care utilization rates are faced with increased risk of developing chronic diseases. In fact, these patients often have multiple diagnoses of chronic diseases such as heart disease and diabetes. In addition, they often have limited resources to manage or treat their illnesses. Barriers to optimal care include lack of transportation, poverty, and low literacy levels. There are 10 CCT providers throughout Maine. They are designed to improve care and reduce avoidable costs for patients with complex or chronic conditions by helping with management of health care services. Healthy eating is integral to overall health, and nutrition education can complement existing CCT services to optimize patient support.
Solution
The Maine SNAP-Ed CCT project works to engage CCT patients in Androscoggin County with interactive nutrition education sessions led by Nutrition Educators. CCT case managers encourage their patients to participate in the classes by developing promotional materials, calling patients to remind them of upcoming sessions, and even arranging transportation services to classes.
The CCT project utilizes evidence-based curricula based on the USDA Dietary Guidelines for Americans. These concepts are integrated into interactive lessons to teach cooking, food safety, and food resource management skills in the grocery store setting. Family members are encouraged to attend the classes to help reinforce the lessons at home.
“When we initially started the CCT, we had a patient that met the CCT staff at the Nutrition Center. The patient was a diabetic and living on limited funds and buying food was very tough. The patient came to the SNAP-ED class and was taught by the nutritionist how to shop for healthy food on a budget. This was very helpful to the patient. In addition, the patient was able to cook a healthy meal and have socialization.”
—CCT Partner
Sustaining Success
In its first two years, implementation of the CCT project in Androscoggin County has proven to be very successful. Community partnerships have formed and expanded. Partnering agencies are very satisfied with the CCT project and find the approach applicable and effective. They also indicate that this targeted approach to delivering direct education provides a much-needed service for this high-risk population. Patients are being exposed to curricula that teach them how to shop, cook, and eat healthy on a budget – education they are not regularly receiving in their Patient Centered Medical Homes.
Going forward, the Maine SNAP-Ed Nutrition Educators in Androscoggin County will continue marketing and promotion efforts of this project and will consider expansion of partnerships to increase reach. Reducing transportation barriers will continue to be a priority. In 2017, Maine SNAP-Ed will integrate lessons learned to support additional programming with CCT patients in other regions of Maine.
Partners in Success
- Healthy Androscoggin
- Androscoggin Home Care and Hospice
- DFD Russell Medical Center
- Tri-County Mental Health Services
Maine SNAP-Ed teaches low-income Mainers the knowledge and skills needed to make healthier lifestyle choices. The program has 44 Nutrition Educators throughout the state that implement 7 evidence-based curricula, reaching the entire age spectrum.
In 2016, Maine SNAP-Ed delivered 11,548 nutrition education classes, reaching a total of 34,190 youth and adult participants.
In 2015 and 2016, Maine SNAP-Ed reached 252 high-risk patients in Androscoggin County.
This post was submitted by Maine SNAP-Ed. For more information, please contact mainesnap-ed@une.edu or visit www.mainesnap-ed.org.