Tidelands Health – Tidelands Community Care Network

What is it?

The program’s primary goal is to facilitate access to care at the right time and in the right place. The Tidelands Community Care Network (TCCN) uses a dual approach of providing care coordination and patient navigation services while also working with community partners to address systemic, cultural and generational barriers to care and improved community health. The integrated care team includes two community health workers, an intake coordinator,  six care coordinators, five high-risk registered nurses, and two community nurse educators who focus on chronic disease care pathways and alignment of care needs with TCCN participants and their medical homes. The TCCN team also includes a Welvista representative to facilitate access to medications and an Americorps VISTA volunteer responsible for developing a system for sustainable program elements, such as data management, analytics and policy development.

Tidelands Community Care Network is built upon collaborations and has made numerous strides over the last few years as a result of these strong partnerships. Recent notable collaborations include:

• A partnership with Tidelands HealthPoint Center for Health and Fitness and the Georgetown YMCA – Provides scholarships for low-income individuals ready to engage in fitness activities for better health. The partnership includes health coaching, exercise training and access to Tidelands HealthPoint and the Georgetown YMCA.

• Feeding Hunger and Supporting Nutrition – A Tidelands Community Care Network initiative to engage food pantries and free meal service providers to offer healthier options and more consumer choice. For example, Friendship Place is redesigning all of their meal site menus in consultation with local chefs to move from meat- to plant-based diets.

• The Transportation Collaborative – A group focused on increasing transportation resources. After two years of collaborative planning, development and instituting low-cost changes, the Georgetown Transportation Collaborative secured a $13,000 grant to implement new transportation resources. This work includes the development of a community transportation guide and a pilot wheelchair assistance initiative for non-Medicaid community members who require wheelchair transport.

TCCN will continue its collaborative efforts to benefit the community.

Who is it for?

Adults ages 19 and older who need health care but have encountered barriers to accessing or navigating appropriate medical and behavioral health care, health education and care coordination.

Why do they do it?

Much of the county is plagued by historically high rates of chronic disease and poverty. Census data from 2010 indicated that 22.1 percent of county residents live in poverty, a figure that exceeds the state average of 18.9 percent. Most recent numbers indicate that 21 percent of the adult population is uninsured. Census data from 2010 also show that 32.3 percent of Georgetown County residents are obese, and 28.2 are tobacco users. These factors contribute to the area’s high incidence of chronic disease, including Type 2 diabetes, cardiovascular disease, hypertension, chronic obstructive pulmonary disease and end-stage renal disease. They also have contributed to high emergency department use by the uninsured, with a high percentage of these visits resulting in hospitalization. Over the years, well-intentioned efforts to address these problems were uneven and inconsistent.

Impact

Currently, Tidelands Community Care Network is serving 1,665 participants. Since opening the new Community Health Resource Center in May, referrals have increased by 263 percent. Nearly 2,254  primary care visits and 1,691 specialty care visits, including gastroenterology, orthopedics, and general surgery, have been arranged; 561 diagnostic tests have been completed; and for those needing mental health services, 139 behavioral health care visits have been completed.

Contact: Margaret Lamb
Telephone: 843-652-1636
Communications Facilitator, Marketing & Communications
Email: mlamb@tidelandshealth.org