Coordination of Care by Primary Care Practices: Strategies, Lessons and Implications

Documents successful strategies for coordinating care within primary care settings, including family and caregivers; with specialists; with hospital settings; and with community-based services. Discusses challenges, lessons learned, and implications

The Chicago Family Case Management Demonstration: Developing a New Model for Serving "Hard to House" Public Housing Families

Describes the design, development, and implementation of an initiative to provide families with enhanced case management, including relocation services, workforce support, and financial literacy training. Presents baseline findings from a resident survey

Closing The Loop: Pilot Evaluation of Referral Navigator at OneWorld Community Health Centers

Background. Low-income persons are subject to barriers to accessing health care and the additional complexity of the referral process, specifically for those receiving assistance from indigent care programs, contributes to those barriers. The requirements for patients receiving social assistance from indigent care programs leads to increased waiting time to be seen by specialists and contributes to health disparities. Aim. Through a partnership with OneWorld Community Health Centers this project seeks to understand the efficacy of the implementation of a “referral navigator” at OneWorld and make recommendations to enhance the process. The proposed navigator is aimed to decrease the waiting time between the date of referral by the physician and the date on which the patient is eligible to be scheduled at a specialist’s office through HOPE. Methods. Individual interviews were conducted with three referral care coordinators, recorded, transcribed, and coded for emergent themes. In addition, individual chart review was completed in order to determine the frequency for which referrals were being tasked or not tasked. Patient outreach was also piloted in order to assess the efficiency and feasibility of calling patients. The data were summarized using frequency tables and a SWOT analysis was conducted for easier identification of factors that impact the referral process. Results. Interviews with referral care coordinators (RCCs) led to informative conversations that mirrored the sentiments originally presented by the Patient Voice Committee. It was identified that approximately 36% of referrals are not tasked and these non-tasked referral lead to an average initial contact time frame of roughly 24 days. Patient outreach was unproductive due to an only 8% successful patient outreach, 36% of patients were unreachable, and 20% were left a message. From this data, we were able to better understand the efficacy of the implementation of a “referral navigator” at OneWorld and how to reduce the waiting time between the date the referral was entered and the date on which the patient is eligible for an appointment through HOPE. Recommendations of providing a communications refresher training, implementing a referral packet, and implementing a modified referral navigator position were made in order to achieve the aims of this project. Conclusion. Through the pilot evaluation, areas of improvement were identified in order to enhance the referral process. Interventions targeting improvements in communication and follow-through between staff members have the potential for greatest impact on maximizing efficiency. Using the SWOT analysis tools to better visualize the problem, future interventions can be designed and adjusted as needed

Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes

Describes in detail eight change concepts as a guide to transforming a practice into a patient-centered medical home, including engaged leadership, quality improvement strategy, continuous and team-based healing relationships, and enhanced access

Is a Shortage of Specialist Physicians Disproportionately Affecting Access to Care in Rural Counties with Federally Qualified Health Centers: Trends in Texas from 2012 & 2017?

Objective: This study utilized Medicare 5% limited Data sets to compare total specialty care referral consultations for Medicare patients seen at FQHCs in Harris County to those seen at FQHCs in rural Texas counties. Currently, no published data is examining the changes in specialty referral rates for FQHC patients in the state of Texas. Evaluating these trends will allow system executives, public health officials, and patients alike to understand the magnitude of differences in specialty provider coverage in Texas. Methods: A retrospective cross-sectional study was conducted using CPT codes for patients living in selected rural and urban counties across Texas who have completed visit (s) with a specialist provider between 2012-2017. The primary aim of the study is to describe the population health impact of changes in specialty referral practices across the state of Texas. The selected CPT codes measured all defined specialty visits across the state of Texas. Results: The study found a change in the use of specialty referral consultations when comparing the two data years. Study results showed a significant reduction in the usage of specialty services for patients living in rural counties. The reduction may be attributed to a few changes currently happening in the state. Several researchers have indicated that the state is not producing or recruiting enough residents and practicing physicians to meet the growing population demand (Merrit Hawkins, 2018). Conclusion: The population in Texas continues to grow at one of the fastest paces in the U.S. As the population grows, residency programs in the state will need to adapt by creating more spots for residents. More focus will need to be placed in rural settings, possibly offering providers more incentives to work in these environments. As it stands today, many Texas counties have less than two specialists living in them. Hospital systems in these rural counties will also benefit by partnering with FQHCs in the area to ensure that specialty services are rendered by the FQHCs within the communities they serve. Lastly, The Resident Physician Shortage Act, if passed, will provide a much-needed boost of new physicians to the workforce. A boost of physicians in underserved areas, such as the rural counties in Texas, may provide a solution to the physician shortages in these areas

Providing patient-centered enhanced discharge planning and rural transition support: Building a rural transitions network between regional referral and critical access hospitals

Residents of rural and frontier counties experience significant disparities in healthcare access and outcomes when compared to their urban counterparts. The organization of health care delivery contributes significantly to these disparities. Simply put, rural residents can face many challenges when they have to go to a hospital in a distant city for treatment and then return home to recover. The transition back home is also problematic because discharge planning generally does not adequately account for limited access to care in rural areas. The specific aim of this research project was to ascertain rural patients’ actual experience of the discharge planning process, and to involve patients and rural providers in designing and testing a contextually appropriate rural model that improves patient outcomes and reduces re-hospitalizations. This manual was used in a research project, Rural Options at Discharge – Model of Active Planning (ROADMAP). Our objective was to develop and evaluate a model that improved the likelihood of a positive recovery and reduced the likelihood of re-hospitalization. Current trends in health care delivery suggest that the right supports provided to patients at the right time may improve outcomes and reduce re-hospitalizations. For patients being discharged from a tertiary care facility back to a small town or rural community, this support includes assistance in addressing instrumental and social support needs. The methods included in this manual come from the literature, from cutting-edge practices in the field of care coordination, from recommendations of medical care providers, from patients themselves, and from lessons learned through this research process

Pediatric mental health referrals: Guidance and directory for Pediatric primary care providers in New Hampshire

This resource includes both a flyer and a limited directory of mental health services in New Hampshire to support pediatric primary care providers in offering successful referral options for their patients who may need mental health services. The directory includes information such as practice name, address, phone number, website, towns served, Medicaid acceptance, and programs or types of services. The directory does not list the many individual private mental health providers practicing in New Hampshire due to the changing nature of practices, providers, and insurance. However, additional providers may be included in future versions