Why It Matters
Community services - including education, skills training, reliable transportation, and legal services - can be just as critical as comprehensive medical care to improve a patient’s health.
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Moving from the “Medical Home” to the “Medical Neighborhood” to Better Serve Patients with Complex Needs

By IHI Multimedia Team | Thursday, October 15, 2015

The Integrated Care Program at Colorado’s Mountain Family Health Centers (MFHC) aims to not only strengthen clinical care quality, but also to make community services more accessible in order to raise both the physical and mental well-being of Medicaid patients with complex needs. 

Mark T., a Medicaid patient at Mountain Family Health Centers (MFHC) in Colorado, faces a variety of health issues, including diabetes, infections in his teeth, kidney problems, and vision challenges. In addition to his physical health, Mark, like many patients at MFHC, experiences financial and transportation barriers that make it difficult for him to access regular treatment and pay for his medications.

MFHC is working with Mark and other Medicaid patients to address some of the social determinants that can dramatically impact patient’s health. Ken Davis, PAC, Medical Director, and Jolene Singer, RN, Care Coordination Manager, aim to move beyond the “medical home” to the “medical neighborhood” — that is, recognizing that community services like education, skills training, reliable transportation, and legal services are just as critical as comprehensive medical care. A key question helps guide their work: “What is the biggest challenge in this patient’s life?”

Launching a New Health Improvement Model
Inspired by patients like Mark, the MFHC health improvement management team has been dedicated to strengthening clinical care quality, making community services more accessible, and raising the physical and mental wellbeing of its patients. In 2014, with support from Rocky Mountain Health Plans and The Colorado Health Foundation, MFHC broadened this approach by developing a new health improvement model specifically for Medicaid patients with complex health needs in smaller communities.

Called the Integrated Care Program (ICP), its development is guided by the Institute for Healthcare Improvement’s Better Health and Lower Costs for Patients with Complex Needs Collaborative. Mountain Family’s ICP model proposes — especially in health disparate populations — that health improvement management should emphasize positive patient engagement that optimizes the benefits of clinic-provided services and stabilizes care costs, in addition to raising access to and quality of care. Positive patient engagement is the key to the MFHC model’s success with patients with complex health needs who have difficulty sustaining access to their provider and can be unpredictable in their actual consumption of provided quality care.

An estimated 70 percent of this population live with behavioral health conditions or face adverse social determinants. Many individuals in this population skip doses of medication or fail to fill prescriptions because they don’t understand the role medications play in managing their chronic disease, fear of side effects, or lack of funds to pay for medications. As a result, some patients may overuse high cost services, such as the hospital emergency department, which they might otherwise avoid with better medication management.

To better meet the needs of Medicaid patients with complex needs, MFHC clinicians are testing a new integrated primary care delivery model. (Photo used with permission.)

First Year Challenges and Potential Solutions  
The first year of testing (in 2014) the new Integrated Care Program (ICP) model revealed multiple barriers that interfere with the goal of improving health engagement for Medicaid patients with complex needs. These obstacles restrict patients with complex needs from having a genuinely collaborative relationship with their providers and from actively following through with both disease self-management and wellness self-care.

Through its continued testing of the ICP model, the MFHC team is identifying potential solutions for six key barriers:

  • Enrolling and Engaging Patients in the ICP: Typically, patients with complex needs are less engaged in their health and generally don’t have collaborative relationships with their providers. The MFHC team is testing supplementing the existing Patient Centered Medical Home (PCMH) model with consumer-oriented engagement and motivational services to address this barrier.
  • Managing “Upfront Costs”: Supplementing the PCMH model with additional services will add substantial costs. MFHC is designing a business model that tests the cost-efficacy of these new interventions that can minimize waste and ultimately improve outcomes related to primary care.
  • Monitoring Patient Data: Health information systems are not well designed for patients with complex health needs who need PCMH supplemental services. Experience is showing where these patient data deficits are most problematic, and the team is working on identifying recommended solutions that increase the utility of systems for these patients.
  • Applying Risk Ratings: Risk ratings are in an early stage of development and are limited in their applicability to the unique circumstances of patients with complex health needs. The MFHC team is learning which rating model provides the information needed for planning and implementing effective services for these patients.
  • Accessing Community Resources: Most of the barriers preventing patients with complex needs from achieving better health engagement and health status involve social, psychological, and economic determinants. While clinic providers can assess these needs and identify the necessary links between patients and resources, there is a need for a network of resources that is consumer-oriented, shares health care goals, and includes methods for communication between the consumer, the clinic, and community organizations. The MFHC team is helping to identify promising resources based on its experience to date.
  • Accessing Behavioral Health Services: Although many patients with complex health needs have mental health or substance abuse problems, the most cost-effective approach to enhancing engagement and physical health status is uncertain. The MFHC team sees the synergy between connecting patients with community resources and providing integrated behavioral health and care coordination as essential to a solution.

Continued Model Testing and Development 
Although data are not yet available to assess the overall value of these potential solutions, early experience indicates that three core components of the IPC — care management, access to behavioral health services, and community resource access — look promising in providing the needed supplemental services to the care that’s being provided by committed primary care practitioners and their clinical teams. In 2015-2016, as part of its participation in year two of IHI’s Better Health and Lower Costs for Patients with Complex Needs Collaborative, MFHC will continue developing and refining the IPC model. 

MFHC does not yet know what long-term funding will be adequate to sustain cost-effective elements of the ICP care delivery model. The amount and sources of savings, the delivery model’s impact on patient health outcomes, and the appropriateness of the selected services given the unique needs of patients with complex health needs are all under study. Patients with complex health needs very much want and deserve a better quality of life. Without question, there is a primary care model that will help them achieve this reasonable goal, and MFHC is optimistic that its new model is a step in the right direction toward achieving this goal. 

Ken Davis is MFHC’s former Medical Director of Integrated Care. Ross Brooks is MFHC's CEO. Jerry Evans is MFHC's Integrated Care Consultant. MFHC were participants in IHI’s Better Health and Lower Costs for Patients with Complex Needs Collaborative.

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