EVOLUTION OF A PATIENT CENTERED MEDICAL HOME
The aim of the nurse faculty practice in Sandoval County is to demonstrate and teach effective community-responsive practice evaluation and management to achieve sustained impact on New Mexico primary care and the nursing workforce.
Background: The faculty practice initially provided patient care and student teaching as a separate entity of the College of Nursing. Group prenatal through infancy innovations and integrated behavioral health incorporated engagement with patients and the community. An example from group care includes collaboration with the Sandoval County Women, Infants, and Children (WIC) program. Patient education provided by Community Health Workers (CHW) also meets WIC eligibility criteria. Patients attending group save three visits to WIC thereby reducing patient (and Medicaid) burdens of transportation and time away from work or school. Integration of oral health into primary care practice is an example of inter-professional team-based care and care coordination innovations. It increases equity of access to an oral health clinical pathway that crosses organizational boundaries. A business model change resulted in the integration of the faculty practice into the Community Health Center (CHC) organization. Integration enhanced awareness of disparities in patient-centered processes within the CHC. Increased capacity through CHW resources and DNP student learning in quality improvement activities contributed to the decision to jointly pursue PCMH certification.
Brief Description: PCMH results nationally have been inconsistent. Successes appear linked to the presence of locally designed innovative practices that embrace PCMH key attributes, and less so to the certification process itself. There are additional benefits to certification however, as a vehicle for clinic re-design and the potential for increased reimbursement opportunities. The Consolidated Framework for Implementation Research provides the foundation for the PCMH model that will guide the CHC re-design process. Domains include Intervention Characteristics, Outer Setting, Inner Setting, Individual/Team Characteristics, Process of Implementation, Measures of Implementation, and Outcomes.
Outcomes Achieved: Administrative outcomes achieved reflecting key PCMH concepts include expanded integration of the faculty practice into the CHC. This has expanded capacity for the CHC including group care, CHW, integrated behavioral health, quality improvement, and increased access for patients. Patient care activities now occur within a single EHR system. Increased organizational readiness demonstrated through CHC Leadership Team and Board of Directors approval of the certification proposal. Selected clinical outcomes include a 50% increase in completed dental referrals due to CHW interventions. Ninety-eight percent of prenatal patients remained in our care through delivery. Thirty percent of prenatal patients received referral for behavioral health care. Of those, 88% entered care.
Conclusions: Following certification, the PCMH framework will be applied to continuous quality improvement and evaluation activities. CHC re-design through PCMH certification enriches this site for student learning. As a site for BSN through DNP students, experiences include high quality evidence-based patient care, inter-professional teams, and community-engagement. It also affords opportunities for the DNP student in leadership, quality, research, and innovative practice.