Past Marco Damiani, CEO, Metro Customs Health Centers
Behavioral Wellness News, Summer 2017, Vol four. No. 4

Marco DamianiIn an increasingly circuitous and competitive healthcare environment,  ensuring admission to integrated care for our most vulnerable populations is becoming evermore challenging.  Metro Community Health Centers (MCHC) has embraced this challenge and is providing patient-centered services designed specfically for patients with complex needs. MCHC is a Network of 5 Federally Qualified Health Centers (FQHCs) providing comprehensive healthcare services to a culturally various, underserved, and oft medically and behaviorally circuitous patient population throughout NYC.  MCHC'southward team-based model of care includes primary and specialty care, behavioral wellness, dentistry, and rehabilitation services that are grounded in practices that empower and back up each patient's concrete, mental and social well-being.  A significant number of our patients have intellectual/developmental disabilities (I/DD), and while some  challenges to obtaining optimal health are unique to this group, many are concerns that are also seen in other vulnerable populations:

  • Enquiry shows that vulnerable populations, including the economically disadvantaged, racial and ethnic minorities, uninsured, and those with I/DD, experience inadequate access to intendance, poor receipt of wellness care services, and ultimately poorer health outcomes (Hayden, K.F, Kim, Due south.H., DePaepe, P., 2005, Krahn, One thousand.L., Hammond, 50. & Turner, A., 2006, Shui, L, & Stevens, G.D, 2005).
  • Compared with other groups, vulnerable populations are likewise more probable to experience before onset of affliction, greater severity of disease and more preventable mortality (Havercamp, S.One thousand., Scandlin, D. & Roth, Yard., 2004, Wilson, P.Thou., Goodman, C., 2011), and preventable mortality (Havercamp, S.Grand., Scandlin, D. & Roth, Grand.,2004, Horowitz SM, Kerker BD, Owens PL, Zigler Eastward., 2000, Williams, D.R, Mohammed, S.A, Leavell, J., & Collins, C., 2012).
  • Low socioeconomic status groups and individuals with I/DD often struggle with run a risk factors associated with chronic conditions including poor nutrition, obesity, and sedentary lifestyles (Rimmer, J., & Hsieh, Thou., 2011, Pampel, F.C., Krueger, P.M. & Denney, J.T., 2010).
  • Although at greater risk for chronic diseases, they frequently take less access to advisable health intendance services, and prevention services are rarely implemented with this population. (Anderson, 50.L., Humphries, K., McDermott, S., Marks, B., Sisirak, J. & Larson, S., 2013., U.S. Public Health Service, 2002).

Compounding these issues is a express number of healthcare professionals qualified and trained to meet the specialized needs of this population, and a lack of continuity in care. In addition, many wellness centers lack the specialized equipment and supplies needed to adapt a wide range of patient function and ability.  This creates significant access problems for vulnerable/complex needs populations.

Maintaining continuity in intendance is also a critical component of quality healthcare for vulnerable populations.  However, obtaining continuity beyond multiple service systems is challenging.  Many primary care providers do non provide or have set up access to adequate example management services. They often focus on the medical bug at manus and overlook the preventative and social needs of the patient. Limited noesis of resources available tin also leads to poor continuity in care.

What are some key indicators of effective and sustainable intendance for under-served patients with circuitous needs?

  • Integrated Intendance, especially Primary Care and Behavioral Health
  • Accountable Care
  • Holistic Care
  • Strategic Partnerships
  • Community Engagement
  • Robust Health Information Systems

In that location are many other components that provide value to a patient's intendance, but these components, coupled with reliable and fair revenue streams (big surprise!), tin can truly make a difference. MCHC's approach to care, grounded in access for patients of all abilities, starts with a fundamental foundation – the Patient Centered Medical Home (PCMH). The National Committee for Quality Assurance (NCQA) has recognized MCHC equally a Level 3 PCMH. A growing body of prove demonstrates that Medical Homes amend quality of care, health outcomes and patient satisfaction, while reducing health disparities, hospital and emergency room visits and overall costs. An array of on-site services provided under the direction of a diverse squad of primary and specialty intendance providers enables holistic delivery of quality care.

In addition to developing a holistic model of wellness care for underserved and vulnerable patient groups, MCHC also recognized the value in working with a larger grouping of providers to run across quality of care objectives and reduce costs. MCHC is a founding member of the Alliance for Integrated Intendance of New York (AICNY).  AICNY is a unique, state-wide Medicare Shared Savings Plan Accountable Intendance Arrangement comprised of clinical partner organizations that back up 6,000 vulnerable patients across NYS. Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health intendance providers who come together voluntarily to give coordinated high quality intendance to their Medicare patients. The goal of coordinated care is to ensure that patients, peculiarly the chronically ill, go the correct intendance at the correct time, while avoiding unnecessary duplication of services and preventing medical errors (Centers for Medicaid & Medicare Services, 2015).  Clinical and community partnerships are essential in meeting these goals, especially when coordinating care for vulnerable populations who often require a range of services from multiple providers. Unlike many ACOs in New York over the past year or two, AICNY has been successful in reducing the price of care while achieving high quality scores on standardized clinical care measures. Because we have strong healthcare information analytics bachelor to our squad, nosotros are able to specifically rails patient service utilization, cost, diagnoses and procedures and hazard-stratify patients to help inform our care planning.

MCHC is a growing FQHC network in large part considering nosotros accept committed to serving a complex patient population that the general medical community is frequently not prepared to care for. Cognitive Palsy Associations of New York State recognized this when they planned and successfully spun-off MCHC as an independently governed and managed organisation in Baronial of 2015. HeartShare Man Services of New York also recognized the potential of a network of this kind, and consolidated their Downtown Brooklyn Health Center into MCHC'southward network in August of 2016. Strengthening the network even further, NYU Lutheran Family Health Centers provided robust support for MCHC'southward designation as Federally Qualified Health Centers.  The strengthened partnerships and collective strategic and visionary planning of these organizations resulted in an expanded telescopic of customs healthcare and a reinforced commitment to a sustainable healthcare organisation for patients with complex needs.

MCHC's healthcare network, specializing in the care of individuals with I/DD, amongst others, is now amid the largest FQHC systems in the nation with a focus on this population. Other vulnerable populations can benefit from a strategic model of intendance such as the one nosotros accept pursued. Providing admission to primary, specialty, behavioral and dental services in our health centers ensures improved admission, efficiency and coordination of care for underserved and vulnerable patients. MCHC staff is experienced in working with patients with complex needs and is committed to treating patients and their families and back up networks with dignity, professionalism and sensitivity. Our team is e'er seeking out new partners with whom we can strengthen community-based systems of intendance for those well-nigh in demand. At present, more than ever, successful partnerships make and keep healthcare organizations strong and vibrant as we all seek new opportunities and navigate rough waters together.

Behavioral Wellness News, Summertime 2017, Vol iv. No. 4
http://www.mhnews.org/back_issues/BHN-Summer2017.pdf