Health Care Homes Sustainability Roadmap
Care Coordination
By shifting our focus, and our dollars, to prevention and whole person care that addresses physical and emotional well-being, along with social factors such as education, income, housing, and transportation, we can create a more accessible and equitable system to improve the health of all Minnesotans.
Care coordination is a team approach that engages the patient, the clinician, and other members of the Health Care Homes (HCH) team to enhance the patient’s well-being. Organizing timely access to resources and necessary care results in continuity of care and builds trust. A foundational goal of the HCH program is to increase care coordination to support whole person care while advancing broader goals of improving population health and health equity. Effective care coordination is paramount to sustaining the HCH model of care and improved health outcomes.
Strategies
- Identify, implement, and maintain best practices and evidence-informed workflows which support and sustain practice transformation with the goal of improving health outcomes and equity.
- Provide designated staff time to perform care coordination elements, including effective information sharing, goal setting, care planning, follow-up support, and the opportunity to focus on patient and family needs.
- Permit and encourage team members to work at a level that fully utilizes their licensure, training, and skills.
- Incorporate the perspectives of diverse populations into the development of policies, workflows, and the organization’s strategic plan. Leverage individuals within the workforce, such as a community health worker (CHW), who have a close understanding of the community served and is a trusted liaison.
- Implement processes to improve care transitions that reduce readmission, adverse events, and unnecessary emergency department utilization.
Resources
- What Is Care Coordination? | NEJM Catalyst
- Improving Care Coordination in Primary Care
- The Primary Care Collaborative - Home (thepcc.org)
- CMS Care Coordination Toolkit (PDF)
- Care Coordination | Agency for Healthcare Research and Quality
- MDH Community Health Worker Initiatives | Home page (See United Family Medicine story below.)
Stories
“At the core of patient centered care, health care professionals who meet their patients where they are at, engage in active listening, and understand who and where their patients come from, will have more successful patient outcomes.”
In December 2022, Cass Lake Indian Health Services (CLIHS) became a Level 3 certified Health Care Homes clinic. CLIHS is owned and operated by the Federal Government as a Public Health Service Indian Health Service facility.
CLIHS is located within one of seven federally recognized reservations in Minnesota. The organization’s mission is to, “raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level.” Its goal is to, “ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all American Indians and Alaska Natives.”
CLIHS’s awareness and respect of the race, ethnicity and language of those it serves is reflected in workflows, policies and actions of staff. The organization has an effective, standardized process for screening patients for social determinants of health including food, transportation and housing. For individuals who qualify, the team at CLIHS has access to a manual containing a comprehensive suite of patient resources that are available within the organization and the community. The first eight pages of the manual provide staff with background information about the patient population’s history and culture to help educate and remind staff of the importance of respectfully taking both into consideration.
Living in and serving a rural community, CLIHS recognizes the importance of health equity and its impact on patient care. Many of the individuals CLIHS serves struggle with finding reliable transportation. As a result, patients often seek care in the walk-in clinic or the Emergency Department rather than the primary care setting. Without consistent utilization of the primary care team, patient non-compliance has been prevalent and continues to be an ongoing challenge within the community.
To meet individuals where they are at and address one area of non-compliance, a care coordinator developed a biking club for staff members and interested patients. Patients can bring their bike or rent one from the community’s Diabetes Center and join members of their care team for bike rides, conversation, and time together. This activity encourages exercise and ongoing patient compliance. The care team developed a customized exercise routine for a patient with morbid obesity. They exercised daily with him by going on short walks, increasing the distance over time. This individual lost over 200 pounds through the process, an incredible health outcome and source of pride for both the patient and care team members!
The HCH program thanks Cass Lake Indian Health Services for sharing their experiences and insight.
United Family Medicine (UFM) operates as a community health center and designated Federally Qualified Health Center (FQHC), providing comprehensive primary care, dental services, and behavioral health services to an under-resourced and diverse St. Paul neighborhood. The clinic recently achieved HCH recertification at Level 3.
UFM’s redesigned care teams better support patients and leverage the full potential of staff.
“Because we work as a care team, we collaboratively solve problems from multiple angles. For example, one of my patients was having trouble taking her meds. Our team worked together to solve the problem: The PCP pared down the med list. The MA obtained a release of information from a family member so we could share medication information with a caregiver. I called the pharmacy to make them aware of the issue so they could assist the patient in obtaining refills. Lastly, the patient and I organized her medication together in pill boxes. I believe that, through our collaborate work, we avoided a hospital visit for this patient.” -Nadia Higgins, RN, UFM
Care teams are co-located in the primary care clinic and work closely to manage patient care and hand off to one another as needed. Each provider has a RN and MA assigned to them tasked with responsibilities that support panel management. These responsibilities include pre-visit planning, ensuring all follow-up tasks are completed after the visit, and handling between visit correspondences and outreach. A community health worker serves as the primary care coordinator and works with the patient, primary care provider, and the RN/MA to support patients with complex needs. The community health worker is also available to address any identified health-related social needs. A fully integrated behavioral health team supports patients with mental health or substance use issues, and because they are co-located in the clinic, are available to immediately address needs as they come up. Additional support is provided through a diabetes team that includes a diabetes educator and dietician.
The role of Community Health Workers (CHWs) are increasingly being identified as essential to health care teams.
“Being a Community Health Worker has allowed me to positively affect vulnerable communities by serving as a liaison between medical and social services, being an advocate for change, and providing health care services that meet the social, cultural, and linguistic needs of those communities. UFM supports this mission by reinforcing its programs such as our HCH that creates an umbrella of support for those patients who need it the most.” -Lupita Gedang, CHW, UFM
Because UFM screens all patients for health-related social needs every three months, a large part of the community health worker’s role is to address identified needs.
“Our community health worker receives about six referrals a day resulting from positive screens and plays a pivotal role in facilitating and coordinating care for our patients," said Kim Wallingford, director of Clinical Practice & Quality. Health education and promotion is a large part of the CHW role, and she works closely with the PCP and other members of the care team to facilitate patient engagement.
"Community outreach is an important part of the work we do; to inform members of the community of the clinic’s services and to facilitate access to those services," Mary Yang, chief clinical officer added. "The CHW works as an essential community partner and builds relationships with those community-based organizations that support our patients and communities.”
UFM’s patients face many barriers to achieving optimal health including financial, transportation, housing, food, language, and legal barriers.
“It is so nice to have someone looking out for me. Thank you for checking on me," said a UFM patient.
Transportation is a primary need that often impacts patient ability to access the clinic and keep appointments. To address this barrier, UFM has partnered with a taxi company to provide transportation, greatly increasing the number of patients able to keep their appointments, connect with their primary care provider and care team, and maintain that continuity of care that is so challenging to do yet so important in impacting health.
Additional community partners have been identified to refer needs related to housing and food insecurity. And, through a partnership with a law school, the clinic can provide legal services on site two days per week to assist patients with immigration/citizenship, domestic issues, child support and housing concerns.
The HCH program thanks United Family Medicine for sharing their experiences and insight.
Follow the resource link for more information about the MDH Community Health Worker Initiatives.