Community Health Center/Hospital Initiative
The initiative will emphasize three primary areas of focus:
Health Care Access- Core Competencies
The increasing demand for health care services and an evolving health care environment are creating a need and an opportunity to transform how services are delivered. Further, the impact of social determinants specific to this footprint, the prevalence of specific chronic health conditions, and the challenges faced by local populations in accessing timely primary and preventive health care services increases pressure on all parties to find a more effective delivery model. Care is fragmented, providers and organizations often do not share critical information, and funding continues to be primarily based on services provided, rather than outcomes. Further, most models lack an adequate RX adherence component, which is an increasingly critical attribute in improving individual and population outcomes.
A new voice is required to support the collaborative mechanism required for transformation, which supports coordinated, higher quality patient centered care.
Community Health Center/Hospital Collaboration Initiative
The overall goal of this initiative is health care which more effectively "wraps around" the patient, and is more responsive, cost effective and provides better outcomes. In many cases, failure of effective care is not solely due to lack of resources. Coordinated outreach through integrated patient home methodologies forms a key avenue to achieve these goals.
This strategy will seek to expand individual access to health care in three areas:
- Direct Primary Care Services
- Discharge Management for discharging patients with no identified primary care relationship
- Emergency Department Division
All three access point strategies will involve a heavy emphasis on Patient Centered Home Medical (PCHM) infrastructure. Patient Centered Medical Homes are a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand.
The objective is to have a centralized setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient's family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner.
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