The Efficiency of Care Coordination

The Patient – Centered Medical Home (PCMH,) is a model that has only recently picked up traction in our ever-evolving healthcare system. The PCMH is an innovative model for delivering healthcare to patients with an objective of achieving maximum outcomes for health. In its most fundamental form, this model aims to track patients over time while providing coordination to health professionals (in a variety of fields,) in order to provide patients greater access to health care, as well as increasing their accessibility to services and maximizing outcomes.

PCMH stemmed from the research of Dr, Jeffery Brenner, based in Camden, NJ.  He found that the city’s most expensive patients came from two hot spots within the city and that the patients were collectively costing the city close to $200 million in Healthcare bills. From this information, he developed a system which identified the costliest patients, and through a consortium of doctors, nurses, and social workers, the patients were connected with the resources that would help them address their over – utilization and expensive use of the Camden health system. Generally, this meant connecting patients with resources that helped improve their quality of life, whether that meant finding the patient new housing because their house had mold which caused their development of asthma, or getting patients their vital medications which is something many NHC members are very familiar with. Several of our NHC Philly members serve as patient advocates in the Philadelphia Department of Public Health Centers which assists patients in getting access to affordable medications if they are uninsured or underinsured.

Of course PCMH has its problems. Care coordination is very challenging in the web of providers one patient sees and there is no guarantee of patient compliance or follow up.  However in my service site, PDPH Health Center #6, health workers have developed a successful, mini – medical home for some of their most vulnerable HIV/AIDS patients in the Priority Clinic. At each visit, a patient has a comprehensive visit with their physician, is offered help in identifying financial and housing resources, is informed about medications like PrEP or Truvada, and may be visited by a medical caseworker, social worker, nutritionist, and/or outreach counselor. There is also an HIV/AIDS specific information hotline, which is answered by experts who can answer questions and make referrals for providers and caseworkers. The system is comprehensive and effective.

Through casual conversations with the health professionals in my health center and through many patient satisfaction surveys, it is clear that patients in the Priority Clinic are able to get the services they need and are noting improved outcomes. While more funding for the Priority Clinic has aided the success of this PCMH model, I have been so impressed with the quality of resources that Health Center #6 offers to all of their patients. I believe that the emphasis the health center has on ensuring coordinated care, as well as providing necessary and abundant services to their patients has led to patient health and happiness.

This blog post was written by NHC Philadelphia member Anna Porter.
Anna serves as a Patient Advocate for the Philadelphia Department of Public Health - Ambulatory Health Services: Health Center 6.