Promoting medical homes and access to primary care services: Community partnership, care coordination and case management

This study reports on the community component of a demonstration project, funded by CMS, to provide ongoing access to healthcare services for patients who present in hospital emergency departments with primary care needs. The project's model involves partnership of a hospital and nearby FQHC or other community providers and a process of communication/linkages between partners for identifying patients with primary care needs in hospital EDs, referring them to a community provider and providing care coordination, intensive case management and patient education and support services to ensure their future use of appropriate and cost-effective sites of care. The project is piloted in two sites, located in medically-underserved counties with high rate of ED use by Medicaid beneficiaries. Using a data-driven approach, it determines patient's reasons for inappropriate ED use, reviews their barriers and assists them with resolving barriers, including: providing transportation; tracking and reminding patients about follow-up appointments; timely access to services that are culturally and linguistically appropriate and that meet the individual needs of diverse patients; linking with intensive chronic disease management programs; and ultimately helping patients find more accessible permanent medical homes. A three-pronged approach will be used to measure the effectiveness of the project and assess its outcomes and impacts, including CQI, surveys, focus groups and existing data in ED and FQHC utilizations. The anticipated outcomes include reduced ED use; increased capacity of primary healthcare system; more use of community clinics/medical homes; improved patient help-seeking behavior/satisfaction; improved access to preventive and primary care services; and Medicaid cost savings.