Triple Aim: 1. Better Care
The people we serve encounter many barriers to obtaining the care they need. In addition to instability due to poverty and inadequate housing, their health challenges often include multiple chronic medical and behavioral problems. After outreaching and bringing people into our health centers and programs for care, we have to constantly improve their experience of care so that they want to come back and engage in ongoing care. To this point, we are also proud that each of our clinics provides healthy snacks and refreshments, available to all patients. In 2013, we continued to develop our model of co-located services within our federally qualified health centers and our system so that we can easily provide medical and dental care, behavioral health care, substance abuse treatment and referrals, and Adult Day Health Care services for our HIV-infected clients. In addition, we expanded our transportation services, further facilitating access to all of our sites from shelters, housing facilities, and other referral entities.
After our health centers achieved NCQA recognition in 2012 as a Patient-Centered Medical Home (PCMH), Level 3, we fine tuned our model throughout 2013 to ensure that each patient felt that the clinic was organized to put the individual’s needs at the center of his/her experience. We developed a call center so that access to care was facilitated. We ensured same-day access to providers and accommodated all people who walked in without appointments. We enhanced our case management and outreach services. We implemented a team model of care in which each client has a team consisting of his/her provider, nurse, medical technician, and case manager. Finally, we instituted a community advisory board for the health centers to have formal input from the people we serve.
In order to assess the effectiveness of these initiatives, the Quality Management Department conducts patient satisfaction surveys in each semester.
Experience Of Care
Triple Aim: 2. Better Health
Our goal is to keep people engaged with the organization so that they can develop the tools to care for themselves, manage their medical and behavioral challenges, and transform their health and their lives for the better. This individual engagement will be reflected in how well we see improved health outcomes in the entire population of people we serve. For example, for our HIV-infected clients, we provide care and treatment through our health centers, as well as with HIV specialist care, supportive services, groups, and community-building in our Adult Day Health Care program. This individualized care and support helps each of these patients manage their health challenges and reduce their HIV viral loads, which in turn reduces viral transmissions to others. Viral load suppression, along with other prevention measures, has a tremendous impact on the public health of a community.
In addition, Brightpoint has strengthened its grant-based HIV and STD (sexually transmitted disease) preventive programs, which have focused their outreach efforts on the group of New Yorkers most at-risk for new HIV infections: young men of color who have sex with men.
Our data gives a meaningful assessment of our strengths and weaknesses. During 2013, our Quality Management Department developed data-driven dashboards for all clinical services so that the opportunities for improving the health of our populations are rapidly identified and action plans are put in place.
Quality of Care
Triple Aim: 3. Lower Costs
Research has demonstrated that integrated models of care with co-located services and care management improve access and retention in care. Within this model, high-risk/high-cost patients can be identified for focused interventions to improve health indicators and avoid unnecessary access to inpatient care. Over 2013, we began to develop infrastructure to identify these patients and to assess whether we can demonstrate savings in our model of care. Towards this end, we began to build relationships with managed-care companies to track our high-risk/high-cost patients so that we can obtain real time data on hospital or emergency room admissions and coordinate discharge planning. This is a predictor of readmissions and reduction of high cost inpatient care.
Here is the idea:
- Establishing relationships with patients’ managed care plans for collaboration
- Obtaining real-time notification when patients have ER visits and/or hospitalizations
- Scheduling follow-up care to prevent hospital readmissions
- Developing care team models to address social determinants of health and ensure retention in care
- Assign medical case managers to high-risk, high-cost patients