In 1973, ChesPenn Health Services opened its doors with one pediatrician seeing patients in a double-wide trailer in Chester. Today, ChesPenn serves over 13,000 medical patients and 5,000 dental patients, many of whom live at or below the federal poverty level. This Federally Qualified Health Center provides comprehensive primary and preventative healthcare, dental care, and social services to under-served families and individuals. About 85% of the patients are covered by Medicaid, but ChesPenn is committed to provide care regardless of income or insurance status. Each health center (located in Chester, Upper Darby and Coatesville) is highly integrated. If a patient comes in for a medical issue and the staff learns that they can’t afford groceries, the patient will be connected to a food assistance program.

One of ChesPenn’s long-time patients is “Stella”, a 59-year-old woman who suffers from hypertension, type II diabetes, chronic kidney disease, liver issues, and has had a history of strokes. Upon her most recent hospital discharge she needed to schedule follow-up appointments with seven specialists. After six visits to the emergency room, ChesPenn’s staff, led by Dr. Tina Ahmadinejad, pictured above, helped her manage multiple medications, specialist visits, transportation to each appointment, and medical equipment. Community health workers will be added to Stella’s team, so she can have an additional layer of support in her home to help with ongoing health and nutrition coaching, monitoring her medication regimen, and keeping medical appointments.

This intensive care coordination has been instrumental in keeping Stella healthy and out of the hospital. Today, she is feeling much better and has not had an emergency room visit or hospitalization for three months.

With an inaugural grant from The Foundation for Delaware County, ChesPenn has initiated a Complex Care Patient Program to better serve high risk and repeat patients like Stella. Stella’s care is a beautiful example of how the Complex Care Program works. High risk patients are identified by repetitive emergency room visits, hospitalizations and the use of multiple medications. A social services coordinator helps high-risk patients understand why it is important to eat well and schedule regular doctor visits. They also adjust the patient’s physical environment so it is best suited to meet their health needs, and promote nutrition and exercise (if they are able). The program will start in Chester and will expand to other locations if they secure additional funding and can find qualified skilled health workers, which is also a challenge.

For more information about ChesPenn Health Services and to find out how you can support this organization please visit their website.