Have you ever wondered what the Health Outreach Department does at Chesapeake Health Care? Let’s take a closer look at how this dedicated team of HOPs supports our patients, community, and staff, and how they work to improve lives and remove barriers to care!
Our HOPs team is a dynamic group of Community Health Workers, Social Workers, Nurses, Medical Assistants, Coders, Data Analysts, and our Transportation Team. Their offices are located in the Tree Sap Admin Building (next to Delmarva Pharmacy) and at South Division Street. But their outreach extends far beyond—through home visits, community events, phone calls, and even on the road. They meet patients where they are on their health journey!
Focusing on Population Health, the HOPs tackle key Social Determinants of Health like transportation, food insecurity, housing, safety, and isolation—all barriers that impact well-being.
Recognizing that transportation is a major hurdle, CHC created its own Transportation Team to help qualifying patients get to their CHC appointments across all three counties. Case Managers provide crucial support to patients and families, connecting them with resources and ensuring continued care.
The HOPs also play a vital role in Transitional Care, following up with recently discharged patients to review instructions, reconcile medications, and arrange needed services to prevent complications. Their Clinical Care Managers assist patients in managing chronic diseases like diabetes, offering coaching and preventive screenings to improve outcomes.
The Emergency Room Utilization Team works to reduce unnecessary ER visits by following up with discharged patients, ensuring they understand their care plan, and reconnecting them with their primary providers.
Data analytics is another key aspect of what the HOPs do, helping to identify at-risk populations and track patient progress for more personalized care. They also assist with quality measures, ensuring compliance with preventive screenings and appointments across pediatrics, OB/GYN, and adult care.
The HOPs Department embodies CHC’s vision of healthier communities, breaking down barriers to care and improving lives. So, the next time you see them out and about in the community, hear their voices on the phone, or receive an email from them, know they’re making a difference every day!
