Promoting medical homes: A model for community partnership, care coordination and case management

This study reports on findings from a survey of patients who used hospital emergency departments for primary care needs and were referred to community health centers to serve as their medical homes. The study was part of a CMS-funded demonstration project that pilot-tested a model in two sites (each a partnership of an ED and FQHC) to increase EDs efficiency via express care units, and referring non-urgent patients to FQHCs for follow up visits. Participating FQHCs made process changes to: expand capacity (adding service hours and/or clinical staff); establish electronic linkages to hospital ED for appointments and sharing of patient information; block same-day/quick follow-up appointment times; provide patient education, case management and additional support (e.g., access to providers by phone 24/7, transportation, interpreters, etc.); identify and address barriers to keeping appointments; and enhance health center services to provide all domains of medical home serving these patients. Project patients, referred from an ED and returned to FQHC for at least second visits, were surveyed and data was collected on their perceived health status and experiences with the care and services received to assess the medical homeness of FQHCs. A total of 120 patients responded, with 86 percent identifying themselves as having a personal doctor at the practices and 70 percent responding that health center staff helped coordinating their care, among other findings. This study will examine association of patients' perceptions with additional patient information, including their demographics characteristics, health issues, source of health coverage, and barriers to accessing primary care services.