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Chronic Disease Prevention & Management Patient Navigator Program
Goodwin Community Health Center, Inc.
dba Coastal Medical Access Project 
900 Bay Street
P.O. Box 1357
Brunswick, Georgia 31521
Project Director: Patricia J. Kota, RN, MSPL, Chief Executive Officer
The Chronic Disease Prevention and Management Patient Navigator program is designed to improve health care outcomes for uninsured adults residing in Camden, Glynn and McIntosh counties in southeast Georgia .
The Coastal Medical Access Project operates two free primary and specialty health care clinics that have since 2002 served uninsured adults in the three target counties, providing access to free and low-cost medications. The Coastal Medical Access Project is the only provider of these services in the target area.
The three counties, with a population of 151,880, are partially rural and have significant rates of poverty and lack of health insurance. The area faces significant health issues that contribute to poor health outcomes of residents. Obesity, tobacco use and physical inactivity are lifestyle concerns that contribute to the development of chronic diseases.
The region also has health disparity concerns, such as higher rates of diabetes among African Americans, and higher death rates from cardiovascular disease than both state and national rates.
More than 15 percent of residents in the three counties do not have health insurance.
The Chronic Disease Prevention & Management Patient Navigator Program program builds on a long history of informal and successful chronic disease case management by nursing staff at the clinics.
To increase the impact of the case management services on the population of patients with chronic disease, the Coastal Medical Access Project is developing a formal and comprehensive chronic disease prevention and management program for patients with chronic disease, including implementation of a patient navigator model.
The chronic disease prevention and management pilot program was launched at St. Mary's clinic early in 2008 with 16 clinic patients with diabetes.
Patient navigators are a critical part of the chronic disease prevention and management program's future growth. The Coastal Medical Access Project plans to incorporate both social workers and trained lay persons in the patient navigator role.
The Patient Navigator program will initially focus on patients with diabetes or cardiovascular disease and will expand to other chronic diseases based on the incidence of those diseases among the Coastal Medical Access Project patient population.
The Chronic Disease Prevention and Management Patient Navigator program targets uninsured adults with chronic disease whose incomes are within the 200 percent of the Federal Poverty Guidelines and who live in the three counties.
Plans to expand services to include employer groups and large employers that are self-insured are under development and are key to the program.
Revenue from contracts with employers will generate funds that will support the program by 2011. The Chronic Disease Prevention and Management Patient Navigator program will recruit, train, employ, assign and manage six patient navigators over the two-year grant period.
The patient navigators will provide
- patient assessment,
- case management,
- health literacy and education,
- psychosocial support, and
- self management education and support (Stanford Model and Motivational Interviewing).
Page last updated: October 8, 2008
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