As a result of escalating medical care costs and national health care reform, community health centers are receiving well-deserved praise and attention for their cost-effective and high-caliber health services. Community health centers are particularly well suited to adopt the Patient Centered Medical Home (PCMH) model, a health delivery system which incorporates finely coordinated medical care that responds to the needs of the “whole person.” Patients from underserved and vulnerable populations can especially benefit from the personalized and detailed care found within the PCMH model. Community health workers, outreach workers, promotores, and health educators are uniquely positioned to identify and respond to the medical and social service needs of different populations in their area. Their involvement in these activities helps to fuel a well-coordinated and successful PCMH.
On May 26, 2011, Health Outreach Partners hosted the national Peer-to-Peer Event, “The Role of Outreach in the Patient-Centered Medical Home” including three panelists:
- Katherine Brieger, Chief Operations Officer, Hudson River Health Care;
- Leo Gaeta, Program Director, Columbia Basin Health Association;
- Kelly Volkmann, Health Navigation Program Manager, Benton County Health Services.
Highlighted below are select observations, strategies, and recommendations discussed during the event.
General Observations
- Prior to becoming recognized, one participant indicated that their health center already had certain practices in place that supported their development as a PCMH. For example, their membership in Plane Tree, an international organization that promotes patient-centered care, helped “lay some of the groundwork” for implementing the PCMH criteria. For more information about Plane Tree, visit: www.planetree.org.
- Although patient-centeredness is not a new concept to many community health centers, the National Committee for Quality Assurance’s recognition criteria delineate specific practices necessary to ensure safe, cost-effective, and coordinated care. One panelist indicated that despite their health center’s long-standing commitment to patient-centeredness, certain internal systems needed to be changed in order to ensure follow-up reporting on all patients and use of electronic prescriptions, as well as tracking of referrals and test-taking. Outreach staff and other care team members needed to be trained on these new systems.
- The PCMH model is a more effective response to chronic illnesses due in part to the emphasis on coordinated care supporting lifestyle self-management. Outreach staff has an integral role in identifying, referring, and following-up with these patients.
- Having the outreach staff occupy the same main health center site along with the WIC office, the county public health department, the immunizations program, and mental health services directly supported care coordination criteria for the PCMH recognition process. The panelist commented, “This has made it possible for us to be very centric in our provision of services.”
Suggested Strategies & Recommendations
- Involve outreach staff during formative discussions and meetings about the PCMH recognition process.
- Integrate outreach staff into ongoing coordination and training with patient care teams; specific outreach staff roles may include: informing the team of what occurs with their patients in the community, charting and using the electronic medical record system, contributing to needs assessment activities, and performing basic clinical procedures (i.e. taking blood pressure, glucose screenings, etc.).
- Outreach staff can also uphold care management in their role through health education activities, chronic disease self-management, and support with mental health services. For example, outreach staff may assist patients with diet and exercise needs and/or support with stress management.
- In the PCMH model, each patient is empanelled or assigned to a patient care team. Possible roles on the team may include: providing input into chart reviews, scheduling lab and provider appointments, as well as supporting medication adherence and refills.
- Recognize the essential role outreach staff has in fostering accessible services, a core tenant of the PCMH model. Examples of these services include: 1) the delivery of culturally and linguistically appropriate referrals; 2) assistance with connecting patients to social services; 3) support with transitions between providers and other phases of care; 4) help with filling out forms; 5) facilitation of transportation assistance; and 6) aid with interpretation.
- Connect with a state primary care association to gain additional PCMH resources.
- Outreach staff demonstrates patient-centeredness through acting as a “cultural broker,” developing relationships, advocating for individual/population needs, increasing health literacy and empowerment, as well as modeling advocacy for oneself and family needs.
- Electronic health records (EHR) are a core tenant of the PCMH model. One panelist shared the need to provide patient education on what to expect from the EHR process as well as addressing questions about confidentiality of the records. This is another potential role for outreach staff. Additionally, the panelist highlighted the importance of such basic considerations as evaluating the placement of computers. For example, computers placed in between the patient and the care team member threatens patient-centeredness because the positioning impedes their interaction.
- Identify a fellow health center and talk with them about their process of becoming a PCMH and the role of outreach.
- PCMH pilot projects have demonstrated that health outcomes improve through holistic attention to the patient. Outreach staff contributes to these improvements through bringing critical information about the patient’s context outside of the health center to the care team.
- Request HOP training on outreach programs and care coordination in the PCMH context; ensure that representatives from all departments attend.
- Collect data and stories that effectively demonstrate results of outreach activities on patient care; discuss specifically how these activities support the PCMH.
- Find a champion for outreach’s integral role in the PCMH; make sure their voice is heard along with the voices of outreach staff directly.
Conclusion
As one panelist discussed, becoming a PCMH was a journey that took a few years for their health center and they are still in process with it. Outreach staff offer multiple and varied ways to contribute to the development of a PCMH model over time. Most importantly, patient experiences and outcomes will benefit from their advocacy, education, and accompaniment through the health and social service systems.
If you want to discuss the strategies above in more detail, please contact Health Outreach Partners at 510-268-0091.