Gothenburg Health has been awarded $309,000 in grant funding to expand its chronic care management (CCM) program through the Rural Health Transformation Fund and the Nebraska Chronic Disease Management Navigation & Education Initiative.

Shay Holbrook, director of population health, said the funding will allow the organization to significantly broaden services aimed at improving outcomes for patients with chronic conditions.

“Initially, it seemed that Gothenburg Health might be disqualified because our current CCM program is already ahead of the curve,” Holbrook said. “However, our application focused on expanding our program and the positive impact that growth would have on our patients. I would love to see the CCM program double in size, but achieving that requires additional staff and resources.”

The expansion plan targets enrollment of 300 patients with chronic conditions, including at least 120 focused on diabetes management. The initiative also includes offering 200 patients individualized navigation services, connecting them with a transitional care nurse for appointment scheduling and post-discharge support, a clinical pharmacist for medication review and a registered dietitian for nutrition counseling.

“Our goal is to help patients remain healthy, active, and engaged in their care,” Holbrook said. “By preventing emergency room visits and hospitalizations whenever possible, we can reduce complications and help slow the progression of chronic conditions.”

The program will also introduce 12 monthly self-management workshops available both in person and virtually, with a strong emphasis on nutrition education.

To support the expansion, Gothenburg Health will add staff, including a second community health navigator. Jennifer Morgan will join current navigator Ana Myers. Hannah Harrison has also been added as the organization’s registered dietitian.

Health officials say the program builds on existing outcomes but aims to significantly improve key measures. Currently, Gothenburg Health reports 45% A1C control among diabetic patients, a 15% hospital readmission rate and 20% emergency department utilization for hypertension.

With additional resources, the organization’s goals include increasing A1C control to 62% among enrolled diabetic patients, reducing readmissions to 10% and lowering emergency department use for hypertension to 12%. The program also aims to assist 200 patients through navigation services, including more than 100 nutrition referrals.

Holbrook said the funding will strengthen preventive care initiatives and expand support services for patients managing chronic health conditions.

For more information about the Chronic Care Management program, contact Gothenburg Health’s Population Health team at 308-537-3661.