Proactively Managing Chronic Disease in Rural and Underserved Areas

The Heart Healthy Communities (HHC) team is committed to designing and deploying new community-centric prevention and intervention models that will reduce health outcome disparities in Arkansas and beyond.

Irion “Chip” Pursell, M.P.H., RN, BSN, Director of Cardiology Research at University of Arkansas Medical Sciences to discusses how Fee-for-service healthcare funding and other market forces created a socially isolated “shadow population” that is unable or unwilling to seek preventative medical care. The consequences of social isolation are devastating, chronic disease, substance abuse, mental illness, and other medical conditions are common. Rural underserved, minority communities are particularly hard hit. No strategy exists to proactively identify and engage socially isolated populations; to combat this growing problem, the HHC team designed and deployed a disease prevention and management model that targets areas with a high risk of poor health outcomes and deploys Community Health Workers (CHW) to proactively engage all individuals in target areas, and link them with local social and medical services. The impact of proactive engagement and linkage to social and medical services is measured by a predetermined set of metrics and measures.