Transforming primary care through a community-based approach

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.