266929 Transforming primary care through a community-based approach

Monday, October 29, 2012 : 5:10 PM - 5:30 PM

Laura Anderko, RN, PhD , School of Nursing and Health Studies, Georgetown University, Washington, DC
Linnea Windel, MS RN , VNA Health Care, Aurora, IL
Tamara Konetzka, PhD , Department of Health Services, University of Chicago, Chicago, IL
Chris Anderko, BA , Big Shoulders, Chicago, IL
Erin Boyle, BS , School of Nursing & Health Studies, Georgetown University, Washington, DC
Blair Johnson , VNA Health Care, Aurora, IL
Patient-centered medical homes (PCMHs) are garnering attention as a potential solution to address financial and performance issues in primary care. However, recent studies highlight limitations such as difficulties in shared decision-making with the patient and health care team, ineffective communication across services, and limitations in the range of health care services offered. VNA Health Care is one of a few Federally Qualified Health Centers (FQHCs) that provide primary care while also operating Medicare-Certified Home Health and Hospice programs. This unique mix of services and organizational capabilities affords an opportunity to improve care, especially for those with complex needs. An alternative primary care delivery model was designed building on the strengths of the PCMH model, while striving to overcome its implementation challenges. This patient-centered health care home (PCHCH) entitled Care Plus offers a broad range of services, a community health nurse as the RN care manager, and ongoing home assessment. Access to a broad range of directly provided services reduces challenges of effective coordination and communication. The RN care manager capitalizes on skills inherent in community health nursing such as building collaborative partnerships, coordinating care, and resource management. In contrast to the PCMH model, Care Plus regularly assesses the patient in his or her own home to more fully understand the patient needs. A randomized clinical trial studying the PCHCH began in early 2011. Preliminary outcomes will be presented and include: patient satisfaction, self-rated health, functional status, and cost outcomes including pre- and post- intervention hospitalizations and nursing home stays.

Learning Areas:
Basic medical science applied in public health
Chronic disease management and prevention
Other professions or practice related to public health
Public health or related nursing

Learning Objectives:
1. Describe key components of a patient-centered health care home (PCHCH). 2. Analyze components of a patient-centered health care home with a patient-centered medical home. 3. List responsibilities of the RN care manager in patient-centered health care home. 4. Discuss preliminary findings from the study PCHCH including patient satisfaction, self-rated health, functional status, and cost outcomes.

Keywords: Community Health Centers, Community-Oriented Primary Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the PI of the research project being reported and have been a public health nurse for over 25 years, including at the VNA Fox Valley
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.