For further information contact:Karen P. Goldstein, kgoldst@peds.bsd.uchicago.edu Vanessa Askot Project HEALTH, Chicago@projecthealth.orgAmy Zimmerman, CMLPC, azimmerman@hdadvocates.org

Medical Home: Addressing non-medical issues by including non-clinic-funded partners in the Quality Improvement (QI) process

Karen P. Goldstein, MD, MPH, MA, Assistant Professor of Pediatrics, University of Chicago, Pediatric Director, FFHC; Leah M. Durst, MD, Medical Director, FFHC; Amy Zimmerman, JD, Project Director, Chicago Medical-Legal Partnership for Children; James A. Mitchell, MA, Case Manager, FFHC;

Emily Brice, BA, (former) Project Manager, Project HEALTH Help Desk

Plans for the Future

Objectives: Partner with community programs in the QI process to enhance coordination of the delivery of medical and non-medical care of patients and improve the overall health of patients.

Target Population: Patients at a Federally Qualified Health Center on the South Side of Chicago serving primarily an African-American inner-city population with many psychosocial, financial, educational, legal,and community-related non-medical needs.

Project HEALTH Help DeskNational not-for-profit organization that mobilizes college students to address the full range of psycho-social needs that impact a family's health and well-being. Multi-lingual undergraduate student volunteers receive extensive training on community issues/resources

• Volunteers at entrance area of health center with banner listing range of services

• Extensive computer database of community resources• Follow-up to assess adequacy and success with services

provided and referrals to community/governmental resources

South Side Chicago Federally Qualified Health Center:

• Internal and family medicine• pediatric and adolescent medicine• obstetrics-gynecology • social services (1 social worker and 4

case management) • nutritionist • on-site WIC program

Inner-city, primarily African-American, patient population:

• 75% of the children/families are at or below the Federal poverty level

• Community experiences high rates of:• underemployment/unemployment • crime • single-parent families• infant mortality rates • no prenatal care

• Public health data documents poor outcomes on health status indicators (deaths from cancer, heart disease, incidence of diabetes, HIV, etc.)

Community PartnersFriend Family Health Center

Abstract

A medical home is not a building, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective. In a medical home, a pediatric clinician works in partnership with the family/patient to assure that all of the medical and non-medical needs of the patient are met (Pediatrics 2002, 110, 184-6).

Establish a Clinical Social and Support Services subcommittee (CS3) as part of the larger health center QI process to promote the connection of essential non-medical services to the medical care of patients:

• Identify and address personal, psychosocial, legal, community and health center barriers to health care

• Improve coordination of non-medical services• Improve documentation of non-medical services in

medical charts• Increase understanding and utilization of health

center and community resources• Improve the overall health of patients and enhance

their connection to the medical home

CS3: Clinical Social and Support Services

Goals

Core committee oversees QI:• Systematic collection of data• Review data at monthly QI meetings• Identify current levels of performance/problems• Propose modifications• Identify resources/personnel responsible• Delineate action steps• Scheduled review of progress

QI Process

QI Subcommittee and collaborative partnership to improve coordination of non-medical services and quality of care. Subcommittee membership comprised of:

• Health center staff: Medical Director, Social Worker, Case Managers, Nutritionist• University of Chicago faculty: Pediatric Director, Developmental-Behavioral

pediatrician• Community partners: Project HEALTH Help Desk Coordinator, Chicago Medical

Legal Partnership for Children Director

Chicago Medical-Legal Partnership for Children

No cost legal assistance for low -income families (excluding criminal or malpractice cases)

• On-site legal consultation-- attorney available one half-day per week at FFHC, by phone for emergency issues and as needed off-site for follow-up

• Legal representation by Health & Disabilities Advocates, Legal Assistance Foundation and pro bono attorneys

• Training of staff, social service personnel, health care providers and University of Chicago pediatric residents

Results: Improved Utilization and Referral Process

Steps Taken:1. Clarified scope of services/expertise2. Developed routing for referrals including those

from multiple sites of service3. Developed tracking of referrals by CS3

subcommittee chair4. Provided feedback mechanism to referral source

and chart5. Created spreadsheet to tabulate referrals

Results:• Single comprehensive CS3 referral form with all

programs and scope of services listed• Referral procedures established and alternative

action steps if provider is not available • Mechanisms for tabulation of referrals to monitor

numbers and sources of referrals• Routing procedures and identification of

responding program provider• Scheduled subcommittee meetings to address

program development, coordination, problem articulation and monitoring of progress

1.Staff and provider review of services available 2. Introduction of combined referral form3.Bimonthly CS3 meetings to continue QI process

• Evaluation of referral processes• Feedback from health care providers and CS3 programs• Measurement of sources and types of referrals generated (comparison with prior CS3

program data and chart audits)• Review of findings from qualitative research project of health center users of CS3

services (K.Goldstein and T. Hamlish, pending)

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