Situation
In a post-merger environment one hospital exists where two previously functioned.
This provides an opportunity to look at community health, and particularly primary care and treatment of chronic conditions, through a highly integrated lens.
Background
In many communities, underserved populations are cared for in a fragmented and inefficient manner.
The emergency department becomes the default setting for treatment of chronic disease – a costly and clinically ineffective model.
Primary care centers with federal qualifications exist in an independent vacuum and often compete for patients along sociodemographic or regional lines.
Hospital-based primary care centers support teaching programs and outreach efforts.
The point: Everyone operates on different information systems and the collective result can be a highly fragmented care process and a collective set of services operating at a loss financially.
Execution
• The vision was to establish a true integrated system engaging two Federally Qualified Health Centers (FQHCs) and the flagship AMC in a joint primary care enterprise focused on collaboration and improving access to services.
• A primary care enterprise was created that bonded the two FQHCs with the AMC to establish a new primary care center and integrated care system.
• A model was established whereby the FQHCs “manage” the primary care offerings for adults and children that support the teaching programs and preserve the FQHC enhanced rate structure.
• Care access was improved through care coordinators and a triage process from ED settings. This enabled patients to become connected with providers and care systems that were better suited to deliver care in more appropriate and patient-focused settings.
• With sponsorship of the AMC, a new and vastly expanded primary care center was created and occupied with services managed by FQHC partners.
Results
The net result was a primary care chassis that now serves as a model for collaboration in efforts like Medicaid population health programs and ensure all providers are aligned and integrated.