Population Health

Complex Care Veterans Services DietitianTCM

Our Population Health services include Veterans Services, helping connect local veterans with available healthcare resources and benefits; Dietitian Services, offering nutrition education and support for healthier living; Complex Care Management, providing additional guidance and coordination for patients with multiple or ongoing healthcare needs; and Transitional Care Management (TCM), which helps patients successfully transition home following a hospital stay and stay connected with the care they need.

Together, these services are designed to provide personalized support, improve access to care and help our patients achieve better health outcomes.

Complex Care

The mission of the Southeast Iowa Complex Care Network is to enhance the care and independence of older Iowans by coordination care services through strong partnerships and shared resources to improve quality of life. 

A complex care program is a support system for people who have a lot of different health needs at the same time. This program is aimed to bring a team together to help coordinate your health care, and social needs.

Our goal is to bring together medical, social and emotional support so people with complicated health needs can have the confidence to live a healthy, stable, and independent life.

What is Complex Care?

• Working with 2 or more chronic conditions
• Connecting with community resources
• Promote safety and stability
• Bridge between home and doctors
• Building partnerships with patients and care team
• Navigating daily life with confidence
• Assist with specialty navigation
• Being heard, respected, and understood as a whole person

Care Coordination Education

• Creates personalized care plans based on the patient’s health conditions and goals
• Coordinates appointments across multiple providers (primary care, specialists, etc)
• Ensures communication between all members of the care team so everyone is on the same page
• Help manage medications
• Provides education about conditions, treatments, and self-care strategies
• Advocates for the patient within the healthcare system

Social Services:

• Assess social needs like housing, food access, transportation, finances, and safety
• Connects patients to community resources
• Helps with benefit applications
• Advocates for patients when navigating social systems or resolving barriers
• Support long-term stability by helping patients develop skills and connections that improve independence

Nutrition

• Creates individualized nutrition plans that fit the patient’s health goals and daily realities
• Provides education on managing conditions like diabetes, heart disease, kidney disease, obesity, or malnutrition
• Supports patients with limited resources
• Monitors progress and adjusts nutrition plans as health needs change
• Teaches strategies for meal planning, grocery shopping, and cooking within the patient’s abilities.

Medical Management (Primary Care Provider)

• Oversees the patient’s overall medical care, ensuring all treatments align with their health needs and goals
• Conducts comprehensive medical assessments to understand chronic conditions, symptoms, and risks
• Manages and adjusts medications, including prescribing, deprescribing, and monitioring side effects
• Addresses acute medical issues that arise between regular appointments
• Provides patient education about diagnoses, treatment options and self-management

Veterans Services

Van Buren County Hospital wants to help those who have served in the military to improve the quality of care we provide and ensure veterans’ needs are being met. Assistance is available at no cost.

VBCH can help veterans with:

• Applying for VA healthcare services
• Connecting to healthcare services
• Exploring options for local primary care and specialty providers
• Behavioral health screenings to identify needs for services and support

Dietitian

Van Buren County Hospital's Nutrition Services offers individualized nutrition care provided by our Registered Dietitian.

Our Dietitian provides a variety of evidence based nutrition therapy services to meet your personalized nutrition needs.

What is a Registered Dietitian?

A Registered Dietitian is a health professional who have completed extensive education and training, credentialing, and licensure in order to provide evidence-based nutrition therapy. A dietitian is the food and nutrition expert!

What are the benefits of working with a dietitian?

• Credible source for food and nutrition information.
• Tailored nutrition advice for your individualized goals.
• Help managing chronic diseases.
• Guidance and support for navigating your specific nutrition needs.
• Improve overall health and wellness.
• For more details or questions contact Elizabeth Wilson at 319-293-3171 ext.1351.

We can provide services for:

• Diabetes/prediabetes
• Weight management
• High cholesterol
• Hypertension
• Pulmonary disease
• Liver disease
• Gastrointestinal conditions
• Heart failure

Diabetes Program

Van Buren County Hospital and Clinics is beginning an exciting diabetes program through our Population Health department.

We have created a team of experts to help improve the health of people living with diabetes. Our team consists of a primary care provider, a dietitian and two registered nurses.

The registered nurse will help you identify a provider that can assist you in monitoring your labs and managing your medications. They can also help you set goals to ensure diabetes management.

VBCH’s dietitian can help improve your education and understanding of nutrition, as it relates to your diabetes and overall health.

Complete the Diabetes Program Form and provide it to the clinic receptionist. Upon receipt of the form, we will be in touch to set up a time to discuss the program in more detail.

Tips from a Dietitian:

• Avoid beverages with added sugar. High amounts of added sugar in your diet can lead to weight gain, obesity, type 2 diabetes, and heart disease.
• Make half your plate vegetables. Vegetables are packed with nutrients like vitamins, minerals, and fiber. Adequate fiber intake can help with cholesterol, gastrointestinal health, weight management and blood sugar regulation.
• Eat a variety of colorful fruits and vegetables. A colorful plate can provide a variety of nutrietns important for maintaining health and protecting against chronic disease.
• Always seek food and nutrition advice from a Registered Dietitian.

TCM- Transitional Care Management

Transitional Care Management helps you stay safe and supported after you return home from the hospital or skilled nursing facility. It focuses on preventing complications, avoiding unnecessary readmissions, and making sure you have what you need—especially important in rural areas where care may be farther away.

What TCM does for you:

• Helps you understand your discharge instructions and recovery plan
• Reviews your medications and explains any changes
• Checks in on how you’re feeling after you get home
• Helps schedule follow‑up appointments
• Connects you with local or regional services, including home health, therapy, or equipment
• Identifies challenges common in rural areas, such as transportation or limited access to specialists

What to expect after you get home:

A member of your care team will call you within a few days of discharge.

During this call, they may:

• Ask how you’re feeling and whether symptoms have changed
• Review your medications
• Help arrange follow‑up visits
• Talk through any barriers you’re facing at home
• Answer questions about your recovery
• This call is supportive but does not replace emergency care.

Your Follow Up Visit:

A follow‑up visit with your provider usually happens within 7–14 days. Depending on your location and clinic availability, this may be:

• An in‑person visit
• A telehealth visit if travel is difficult

During this visit, your clinician will review your hospital stay, check your symptoms, and help coordinate any additional care you may need.

Medication Safety:

After a hospital stay, your medications may change. TCM helps ensure:

• Your medication list is accurate
• You understand what each medication is for
• You know how and when to take them
• You have a way to get your prescriptions filled, even if your pharmacy is far away

Support for rural living:

TCM can help connect you with:

• Home health services (if available)
• Physical or occupational therapy
• Telehealth options when travel is difficult
• Transportation resources
• Community programs
• Medical equipment or supplies

If you live far from your clinic, let your care team know there may be alternatives to reduce travel.

How you can help your recovery:

• Keep your follow‑up appointments
• Bring your medication list to visits
• Ask questions when something is unclear
• Share any challenges you’re facing at home, including transportation or access to services

When to Seek Immediate Care:

If you experience new, worsening, or concerning symptoms, contact a qualified healthcare professional or seek urgent medical attention. TCM is supportive but does not replace emergency care.