Access to Care for the Under and Un-Insured: The 21st Century Model of Primary Care for Chronic Disease

Background: The Mississippi Delta, an 18-county rural region of Mississippi, has one of the highest rates for chronic disease morbidity and mortality in the United States. Low educational attainment, high poverty rates, and low health literacy contribute to the poor health status of the region. Methods: The Delta Health Alliance (DHA) 21st Century Project has provided tools, best practice guidelines, and staff to two primary care clinics, in Washington and Humphreys Counties, soon expanding to Sunflower and Leflore Counties. The clinics support efforts to improve chronic disease prevention and control and has affiliated with two primary care clinics that will transition from a traditional approach to primary care services to a patient-centered medical home model, using a systematic approach developed by TransforMED. This model is both physician and resource sparing, and utilizes a team approach. Patients are now receiving the services of a nurse practitioner, a clinic nurse, a patient navigator, a registered dietician and a clinical pharmacy specialist. Results: Data from the Good Samaritan Health Center indicates over an 800% increase in total services provided to the working uninsured, providing services and increasing clinic hours to the under and un-insured where no services previously existed. Discussion/Implications: The staff is filling a gap in services previously unavailable to uninsured patients, many of whom have never had access to this level of chronic disease education. The TransforMED model has now been successfully reproduced in two different communities in the Mississippi Delta early data from the sites show similar improvements.