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Social factors often play a large role in health. For example, if an individual is lacking stable housing, proper nutrition, transportation to medical appointments, or understanding of their diagnosis, existing health conditions will only get worse, even if medical care is available. In 2014, UNC created its Community Health Department as a bridge to connect health care and social services, with the goal of improving health outcomes for at-risk individuals.
The primary service provided by the Community Health Department is one-on-one care coordination. Through this service, trained nurses work directly with clients to navigate them through the process of accessing health care, as well as to help them overcome barriers they face to receiving care. These services are provided at no cost to participants and have quickly proven to be effective in improving the health of clients.
In addition to care coordination, the Community Health Department also takes an active role in coordinating health education and outreach programming, screenings, and clinics targeted to reach a broader audience of at-risk individuals. For example, the Department is currently working in partnership with the United Way of Lackawanna & Wayne Counties and the University of Scranton to conduct the Telehealth Intervention Program for Seniors (TIPS). Through this program, trained students from the University visit senior centers to measure attendees’ vital signs. This data is then transmitted to UNC’s nurses who review it remotely and follow-up as needed.
In an effort to continue treating the consumer holistically, the Community Health Department has recently incorporated licensed clinical social workers to address the mental and behavioral health barriers that our consumers often face. Individual counseling appointments are available for issues including but not limited to depression, anxiety, grief, substance use, trauma, relationship issues, and life transitions. The social workers can assist in navigating resources such as rehabilitation, support groups, or medication management as well as connect them with any social needs they may have, i.e. food, clothing, housing, prescription assistance, etc.
Another innovative program that UNC offers is the evidence-based Chronic Disease Self-Management Program (CDSMP), which uses trained peer health educators to educate individuals with chronic diseases on how to better manage their illness. UNC has several peer health educators trained through Stanford University to offer the program in both English and Spanish, as well as to focus on specific topics, such as diabetes and pain management.
TIPS and the CDSMP are just two examples of the many innovative outreach programs our Community Health Department is involved in. For more information, contact UNC’s Director of Community Health, Meredith McCracken at 570-880-7130.