PATIENT-CENTERED MEDICAL HOME FOR THE HOMELESS DEBBIAN FLETCHER-BLAKE, FNP CARE FOR THE HOMELESS

PATIENT-CENTERED MEDICAL HOME FOR THE HOMELESS DEBBIAN FLETCHER-BLAKE, FNP CARE FOR THE HOMELESS WHO ARE WE? “Care for the Homeless (CFH) fights ho...
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PATIENT-CENTERED MEDICAL HOME FOR THE HOMELESS

DEBBIAN FLETCHER-BLAKE, FNP CARE FOR THE HOMELESS

WHO ARE WE? “Care for the Homeless (CFH) fights homelessness by delivering high-quality and client-centered healthcare, human services and shelter to homeless individuals and families, and by advocating for policies to ameliorate, prevent and end homelessness.” 



CFH provides health care to 8,000-10,000 homeless individuals across the age spectrum annually CFH services include: primary care, mental health, health education, care management, podiatry, dental, SBIRT, psychotherapy, shelter, substance abuse.

Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

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GAPS IN CARE 





The impermanence of housing is a marked characteristic of the homeless population and has significant impact on their health and well-being.

Substance use disorder, mental illness, and history of emergency department utilization create significant gaps in health care for the homeless. Primary care needs of the homeless are often not met in traditional healthcare settings, leading to poor health outcomes in chronic and preventive diseases.

Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

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EVIDENCE 

The rate of heart disease among adults in DHS single adult shelters is 4x the Healthy People 2020 Goal of 100.8 per 100,000 (477 per 100,000 in 2005)*



Sheltered women have increased risk for dysplasia, proportionately higher rates of abnormal Pap smears, low rates of Pap smear screening, and increased morbidity and mortality from cervical dysplasia and cancer. **



Common difficulties in diabetic management [self-reported by homeless subjects] were related to diet and scheduling and logistics (inability to access insulin and diabetes supplies and inability to *coordinate medication with meals).***

U.S. Department of Health and Human Services. November 2000. Healthy People 2020, www.healthypeople.gov /2020/topics objectives2020/ objectiveslist.asp)./ New York City Department of Health and Mental Hygiene, The Health of Homeless Adults in New York City, December 2005, p. 18 **(Hogenmiller, J.. et al., “Self-efficacy scale for Pap smear screening participation amongst sheltered women,” Nursing Research, 56:6, 2007, p. 370). ***(Plumb, James D. “Homelessness; reducing health disparities,” Canadian Medical Association Journal, 163(2), 2000, p.172).

Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

INNOVATION 





Homeless people deserve a home to take care of their healthcare needs A home in which quality outcome is the centerpiece A home built on the triple aim objectives:  Increased

Access  Improved Outcomes  Decreased Cost

Therefore, CFH developed a Patient-Centered Medical Home for the homeless Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

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KEY ELEMENTS 

CFH’s PCMH for the homeless extends across 14 sites throughout NYC to:  Improve

access to care and provide care coordination  Build collaboration with community partners, funders, the Board, patients & staff  Target specific illnesses that are prominent in the homeless population to improve health outcomes  Provide a delivery system that is sustainable, flexible, and understands the unique needs of homeless patients  Provide competent self-management skills  Reduce reliance on emergency departments Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

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KEY ELEMENTS 



Homeless healthcare has been fragmented and heavily reliant on patients seeking emergency care from community health centers, hospitals, and other traditional settings PCMH for the homeless provides a new delivery of healthcare to the homeless

Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

DESCRIPTION OF INNOVATION 

Designation by NCQA as a Level 1 PCMH 



An ambitious idea for a stand-alone Federally Qualified Homeless Health Center

Implementation Strategy: EHR system that connects 14 clinic sites  Collaboration with community partners  Patient outreach and education  Provider staff buy-in and training  Resource allocation  Workflow development  Development of pertinent quality indicators 

Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

MILESTONES, IMPACT & RESULTS  

 



 

A delivery system that provides open access Significant improvement in health outcomes for the patients who are in care Dissemination of lessons learned to other programs Opportunity to be considered a best-practice site by the National Academy for State Health Policy Supplemental funding from HRSA to enhance PCMH status Complete buy-in from staff and providers Allowed CFH to attest for Meaningful Use for nine providers (82%)

Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

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MILESTONES, IMPACT & RESULTS UDS – 2011 Reviewer Summary Report Grantee-Universal

INDICATOR

CFH

STATE

NATIONAL

Pap Test Compliance Rate

64.4%

53%

61%

Diabetes Compliance Rate

75.7%

69%

72%

Hypertension Compliance Rate

70%

61.8%

66.4%

Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

LESSONS LEARNED 







PCMH transforms delivery systems to improve health outcomes for vulnerable populations PCMH does not eliminate the challenges in homeless health care, such as mental illness, substance use disorder, or inattention to healthcare needs, but it creates systems to reduce them Sustainability is difficult and requires targeted resources Buy-in requires careful planning and delivery of the message (patient & staff)

Healthfirst 2013 Spring Symposium Patient-Centered Medical Home: Building Healthy Communities

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NEXT STEPS 

Currently working on attaining PCMH Level 3 Recognition  Application



will be submitted September 1, 2013

Continue to enhance the current delivery system to attain quality goals and decrease costs

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CONTACT INFORMATION DEBBIAN FLETCHER-BLAKE, FNP ASSISTANT EXECUTIVE DIRECTOR CARE FOR THE HOMELESS Telephone: (212) 366-4459 [email protected]

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