For Mary Chambers, a 64-year-old resident of La Marque, February marked a turning point in her life, all thanks to a phone call. “It was when I received a phone call from Miss Vicki—she’s my hero,” Chambers recounts, highlighting the profound impact of UTMB’s Community Health Program and its dedicated care manager, Vicki Cappa, RN.
The UTMB Community Health Program (CHP) was initiated in 2007 as a proactive solution to emergency department congestion. Instead of solely relying on emergency rooms, CHP aimed to redirect individuals to more appropriate care settings. It achieved this by delivering crucial care and disease management services directly within the Galveston community. This initial phase specifically targeted uninsured patients grappling with chronic conditions such as diabetes, hypertension, and heart disease, ensuring they received necessary support and treatment outside of emergency scenarios.
The program’s reach expanded significantly in 2012, driven by the Section 1115 Medicaid Waiver. This expansion enabled CHP to extend its valuable services to patients in Brazoria County and broaden its patient base to include Medicare/Medicaid beneficiaries alongside the uninsured. This growth underscored the increasing recognition of community-based healthcare in managing chronic illnesses effectively.
Mary Chambers’ journey with CHP began following an emergency department visit at John Sealy Hospital in Galveston. Diagnosed with Type 2 diabetes and dangerously high blood sugar, Mary’s situation was critical. Although she had been experiencing symptoms for years, including debilitating leg swelling and pain, navigating the healthcare system with Medicare proved challenging, leaving her feeling unheard and without solutions. Confined to her apartment and barely able to walk, Mary felt despair and hopelessness. “My apartment was like a coffin,” she described, emphasizing her isolation and physical suffering after a recent divorce and the loss of her mother.
Vicki Cappa emerged as the lifeline Mary desperately needed. Within a week of their initial phone conversation, Vicki visited Mary at home, initiating a personalized diabetes management plan. This home visit marked the beginning of a trusting and impactful relationship. “Miss Vicki was the first person to actually listen to me,” Mary stated. “Just talking to her, I felt so much better—I wanted to live and knew I had hope.” Vicki provided continuous encouragement, clearly outlining the steps Mary needed to take and the positive outcomes that would follow her commitment to the program. This clear guidance and empathetic approach were pivotal in Mary’s recovery.
Beyond home visits, Vicki accompanied Mary to doctor appointments and maintained regular phone contact, offering consistent support and answering any questions. This intensive, patient-centered approach is a hallmark of the Community Health Program. “We work really closely with our patients and get to know them very well,” Vicki explained. “Walking into someone’s home fosters a different, more profound relationship. It’s this close collaboration that’s essential for managing chronic diseases effectively, something that can’t be achieved in a brief 15-minute doctor’s appointment.” CHP provides extensive education, both in-person and over the phone, equips patients with tools like blood pressure monitors and weight scales, assists with accessing financial aid for procedures, and helps secure free medications. The program addresses a wide spectrum of patient needs to facilitate comprehensive care.
To address Mary’s dietary habits, Joshalyn Toliver, a CHP community health worker, accompanied her on a grocery shopping trip. Joshalyn guided Mary through food label comparisons and demonstrated how to make healthier food choices to manage her diabetes. Mary also participated in diabetes management classes and chronic disease support groups offered by CHP, further strengthening her understanding and self-management skills.
Fueled by the support from Joshalyn and Vicki, Mary dedicated herself to transforming her lifestyle. By adopting a healthy diet, consistently taking insulin, and attending regular primary care visits, Mary achieved remarkable progress. She reduced her insulin injections from three to one daily, lost weight, and regained her ability to walk without difficulty. “Mary has listened, she has absorbed everything we’ve provided, and she has truly taken charge,” Vicki proudly stated, acknowledging Mary’s dedication and success.
Mary’s story is one of many successes attributed to the Community Health Program, which assists approximately 500 individuals annually. Alison Glendenning, UTMB’s Director of Outpatient Care Management, emphasizes the broader impact of CHP. She points to examples of patients returning to work after years of hospital readmissions due to chronic conditions and significant reductions in healthcare costs. One patient with multiple chronic illnesses saw their healthcare expenses decrease dramatically from $477,574 before CHP involvement to $97,133 during the program, primarily due to fewer hospital admissions. This data underscores the program’s financial and health benefits.
Data collected since CHP’s inception reveals a 29 percent decrease in inpatient admissions and a 35 percent reduction in costs related to inpatient care. Simultaneously, the program has improved healthcare utilization by increasing outpatient clinic visits. More than half of CHP patients have experienced improved clinical outcomes, highlighting the program’s effectiveness in managing chronic diseases, which are responsible for a significant majority of deaths and healthcare costs in the nation, according to the Centers for Disease Control and Prevention. Alison Glendenning’s leadership in outpatient care management is crucial to these achievements, ensuring the program’s effectiveness and patient-centered approach.
“Successful patients in this program demonstrate high engagement and personal responsibility for their health,” Glendenning notes. “We bring care to the patient and provide the necessary tools, but ultimately, effective disease management is largely dependent on what happens at home—diet, activity levels, and daily habits. While not every attempt is successful, the significant successes we witness are profoundly impactful.”
Mary Chambers is a testament to such success. Confident in managing her health, she looks forward to potentially eliminating insulin injections altogether. “I feel better. I can see down the road. I couldn’t see a block ahead before. Isn’t that something?” she reflects, encapsulating the transformative power of the UTMB Community Health Program and the dedication of professionals like Alison Glendenning in revolutionizing outpatient care.
The 1115 Medicaid Waiver: Fueling Healthcare Transformation
The Community Health Program is supported by the Texas Healthcare Transformation and Improvement Program, known as the 1115 Medicaid Waiver, granted to Texas in 2011. This waiver encourages healthcare providers to collaborate on innovative strategies to achieve the “triple aim” of healthcare: enhancing patient experience, improving population health, and reducing per capita care costs, particularly for Medicaid and uninsured populations. Providers propose projects to Texas Health and Human Services and the Center for Medicare and Medicaid Services, earning incentives for successful outcomes.
Texas is divided into 20 regions, with UTMB serving as the anchor for Region 2. This region encompasses 16 counties and involves 14 performing providers collaborating on 83 projects valued at over $300 million. UTMB’s anchor role includes acting as a liaison between regional providers and Texas Health and Human Services, facilitating the implementation and success of these transformative healthcare initiatives.
For further details, please visit www.utmb.edu/1115.
