Chronic Care Management: A Success Story

Featured and written by CaravanHealth. 

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Tri-State Memorial Hospital (TSMH) takes a unique approach with their Chronic Care Management (CCM) program. Rather than trying to enroll all patients who qualify at once, they use quality data to find areas of care where they can make the greatest impact. They started with diabetes management and built a program that enlists input from disease management experts and keeps them as part of the team. Ultimately, patients are engaged in a provider directed CCM service that maximizes the organization’s expertise, programs, and community resources to help patients and better target challenging areas of care.

Population Health Nurse Nicole Louchart, RN, developed this creative approach with tremendous support from CEO Donald Wee, Chief of Clinical Operations Joleen Carper, and ACO Physician Champion Dr. John Rudolph. Louchart had been recruited for the position by Carper after working with TSMH for more than 10 years. Carper said she saw many traits in Louchart that made her a great fit in CCM, “Nicole is an excellent communicator with patients, families, and providers. She is unassuming and always there to help.”

A recent SWOT analysis confirmed Carper’s assessment: Louchart and the CCM program were identified as one of the organization’s key strengths by TSMH’s leaders and providers. Dr. Rudolph described the value she brings to the program, “Nicole has quickly become the face of CCM, the leader that helped push us into higher volumes while maintaining quality. She brings with her a self-motivated, selfstarter mind frame and is able to come up with and implement new programs and policies. She has created a spark in the program that constantly pushes us all to do more for the patients.”

TSMH agreed to share their experience with building a CCM program and the strategies that play a key role.

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