Health Forward Awards TMC Grant to Implement Project Aimed at Improving Chronic Care Services for Low-Income Heart Failure Patients

KANSAS CITY, MO – Recognizing that health status is largely a function of factors beyond the bounds of the health care system including income, race, environmental and social conditions, the Health Forward Foundation (Health Forward) has awarded Truman Medical Centers (TMC) with a $338,872 grant to develop a new approach to better serve its vulnerable patient population.

The Health Forward grant will support a demonstration project to design and implement a new, innovative approach to chronic care called Guided Chronic Care. In partnership with the University of Missouri-Kansas City School of Medicine, Guided Chronic Care will include an organized, interdisciplinary team, guided by an electronic medical record, that will both assure medical care is based on recognized, evidence-based guidelines and work proactively with patients and their families to address family, social and community support issues.

“Studies show that negative social factors lead to poor health, yet interventions targeting social determinants of health have not always been a focus when dealing with chronic illnesses. This oversight in care is particularly troubling for safety net providers because these non-medical issues frequently impede a patient’s ability to take full advantage of available medical care,” said Steve Roling, Health Forward President/CEO. “We are happy to support Truman in its efforts to develop a program that will work towards eliminating the social barriers that hinder effective medical care.”

The core Guided Chronic Care team will consist of a Social Worker, a Clinical Nurse Leader, a Volunteer Coordinator and a group of community volunteers, a Pharmacist and a Dietician. Interpreters, Behavioral Health Counselors and others will be available as needed.

“Studies have made it clear that chronically ill patients need fewer health care resources and cost insurers less when they are closely supported by a primary care team that tracks their health and offers regular support,” said Shauna Roberts, MD, TMC’s Corporate Medical Director of Quality.

“The ultimate goal is to teach the patient self-management, to make it easier for them to be active participants in their care, and to create greater continuity as we guide patients through the system,” Roberts said. “Part of this is getting the patient connected with physicians and clinical staff who know them, instead of seeing someone new who has to try and figure out what has been going on in their care.”

During the first year of testing and implementation, TMC will enroll 100 patients with a primary diagnosis of heart failure. The project and patient outcomes will be monitored weekly over the next five years.

“With this proactive approach, we hope to decrease the number of patients coming through the emergency room for their primary care, decrease the number of hospitalizations and increase the level of patient satisfaction.” Roberts said. “While the focus of this grant is patients with heart failure, eventually the model will be expanded to include other chronic diseases.”

-Health Forward-

ABOUT Health Forward
The Health Forward Foundation strives to improve access and quality of health for the uninsured and underserved in Kansas City, Missouri, Cass, Jackson and Lafayette counties in Missouri and Allen, Johnson and Wyandotte counties in Kansas. Since it began grantmaking in 2005, Health Forward has awarded $45 million to agencies addressing health needs in the community. For more information, visit

Quality, compassion, technology and innovation are at the heart of Truman Medical Centers. The TMC Health System includes TMC Hospital Hill, TMC Lakewood, TMC Behavioral Health, the Jackson County Health Department and a number of primary care practices throughout Eastern Jackson County. Recently named one of the nations’ top academic medical centers, TMC is the primary teaching hospital for the University of Missouri-Kansas City Schools of Health Sciences and specializes in asthma, bariatrics, diabetes, women’s health, and trauma services. For more information, visit