Community Based Care Models Gaining Momentum with PCMH in Urban Communities

by J. Hunter Young, MD, MHS 

Dr. Young is Ankota's Chief Medical Officer, and serves jointly as Assistant Professor of Medicine at the Welch Center for Prevention, Epidemiology, and Clinical Research, and Core Faculty of Johns Hopkins Bloomberg School of Public Health. In these roles, Dr. Young is involved in population health programs and community based initiatives that are aimed at decreasing readmissions and lowering the overall cost of care. Managing Care Transitions has emerged as a critical element in reducing avoidable readmissions and lowering overall costs, and health care providers are looking for information to guide them in the creation of these programs. 

To learn more about how Ankota technology is used to Plan, Coordinate and Deliver care in community based models and PCMH, click here  

Improving health outcomes and lowering healthcare costs is challenging and usually requires the effort of a multidisciplinary team of professionals. The Patient-centered Medical Home (PCMH) is a team-based care delivery model that addresses this reality and has been effective in achieving better care in many settings. Early evidence suggests, however, that the PCMH model is not as effective in urban settings, largely due to the inability of clinic-based teams to engage urban residents and to address the social, behavioral, and environmental determinants of health that are prevalent in poor communities.

In response, many programs around the country are beginning to supplement their traditional PCMH model with community-based teams dedicated to urban neighborhoods. As demonstrated by Medicare’s Coordinated Care Demonstration Programs, face-to-face interactions between the PCMH care coordination staff and their patients are an essential element of effective care coordination programs. This may be especially true for low resource, urban communities where trust of the health system can be low. Community-based health workers may also better understand the neighborhood-specific barriers to care that limit access for our urban patients.

Community health teams are defined as community-based, multidisciplinary health staff that support primary care and provide linkages between patients and families, and the medical home and the community. Community health teams wrap-around and enhance the capacity of primary care practice.  Core functions of Community Health Teams include patient engagement and assessment, health and social service navigation, mitigation of barriers to care, and self-management support including motivational and emotional support, disease-specific knowledge reinforcement, and on-going monitoring. These functions complement those performed by clinic-based care management staff and together encompass the 6 domains that are critical to chronic disease management as first described by Wagner.¹ Conceptualized in 1996, the Chronic Care Model (CCM) addresses these barriers to patient-centered, high-quality, cost-effective care and has become the standard framework guiding efforts to improve care for patients with chronic illness. The CCM includes 6 elements: 1) health care organization, 2) delivery system design, 3) clinical information systems, 4) decision support, 5) self-management support, and 6) links to community resources. These elements support team-based care that promotes and supports activated, informed, and empowered patients. 

While enhanced PCMH models have only recently been implemented, the early results are encouraging. As presented in a webinar at the National Academy for State Health Policy and sponsored by the Commonwealth Fund in April 2012, preliminary analysis of programs in Alabama, North Carolina, and Vermont have demonstrated decreases in emergency department utilization, overall health care expenditures, and improvements in HEDIS-based performance measures. Many more programs employing community-based teams have been recently funded through other CMS mechanisms.

Therefore, we can expect to see results from these programs in the coming years. 

1.         Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag.Care Q. 1996;4(2):12-25.