Community Health

Shelbie Alexander

Director of Community Health

(660) 542-1695

Community health focuses on improving health outcomes and quality of life for our entire community and population. It involves understanding the unique health challenges within the community and aids in localized strategies to address these issues. Unlike traditional healthcare, community health is centered around social drivers that affect physical and mental health, enhancing access to care and developing community-based programs to combat disparities.

Population Health  

Population health addresses health outcomes with preventative care strategies and coordination that aim to help manage chronic health conditions and promote well-being of individuals within the population.  

The population health team consists of Nurse Care Managers, a Behavioral Health Consultant and Community Health Worker.  

We offer programs such as Chronic Care Management, Transitional Care Management, Primary Care Health Home, as well as Medicaid application assistance.  

Chronic Care Management  

Chronic Care Management (CCM) is a program designed to provide continuous care and support for individuals with chronic conditions such as diabetes, heart disease and hypertension.  

Transitional Care Management

Transitional Care Management (TCM) is a program aimed at ensuring a smooth transition for patients from the hospital or other inpatient setting to their home, and focuses on preventing readmissions and complications by providing medication management and follow-up care coordination, as well as making sure patients have the necessary support.  

Primary Care Health Home 

The Primary Care Health Home (PCHH) is a Medicaid team-based, whole person care program for individuals with chronic health conditions designed to help reduce avoidable emergency department visits, improve care coordination, and provide assistance with disease management and preventative care.  

Annual Wellness Visits 

Annual Wellness Visits (AWV) are preventive health services offered, primarily to Medicare beneficiaries, designed to help prevent disease and disability based on the patient’s current risk factors. Annual Wellness Visits focus on health and wellness, ensuring that patients maintain their well-being as they age.  

Medicaid Assistance

For assistance with Medicaid applications and services, please contact Shandi Duff at 660-542-1695, ext. 3997.