A newly-funded primary care initiative at Atlanta's Morehouse School of Medicine is taking aim at improving care beyond the concept of the patient-centered medical home into a community-based lattice that will enable the creation of a patient-centered medical neighborhood.

"Morehouse School of Medicine has always had a very strong commitment to primary care, delivering good healthcare and clinical medicine to all segments of the community, especially to minority communities and other underserved segments of the population," said George Rust, M.D., co-director of the National Center for Primary Care at Morehouse. "We have also always had a very strong record of community-based interventions – the church programs, the wellness programs, and the prevention models. We've also had a track record of doing some population health outcomes data research. But like most places, those three things have mostly been disconnected from each other."

The school is the recipient of a $1.2 million cash and in-kind grant from United Health Foundation and Optum to support its Medical Home and Neighborhood Project, which provides an innovative primary-care delivery model and community engagement programs in and around Atlanta’s East Point area, a largely African-American community with high rates of poverty and complex chronic diseases.

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Rust says the project will be organized in such a way that he hopes those three components of comprehensive care can indeed be connected. Through a combination of new staffing that includes a nurse care manager, community health workers, a licensed clinical social worker, and the appropriate technology to support them, Rust said the project will combine "high tech and high touch."

The nurse care manager will be asked to provide front-line care as well as analyze trends at the patient panel level. Additionally, the nurse will also serve as the primary point of contact for the project's three community health workers, whom Rust characterized as "essentially peer counselors, or people who are in and of the neighborhood."

These health workers, he said, understand how people in that area live; they speak the language and know what the constraints are in designing and delivering better care, whether it's that patients only get one Medicaid van ride a month, or the buses don’t run after 10 p.m., or where the churches are that have a parish health nurse. The program will depend on these workers communicating quickly with the care manager if, for example, a patient has run out of diabetes medicine.

Likewise, should the nurse-manager notice a patient's lab test numbers have skewed badly or that the patient hasn't shown up for an appointment, she can make a quick call to the community health worker to find that person and take action (the project also includes monitoring of behavioral and social health determinants via the social worker).

"The idea is a collaborative care model that crosses the boundaries of the clinic wall and really bridges between inside the clinic and outside in community intervention," Rust said. "That's what's at the heart of it."

The third leg of the project will be creating a unified data feedback loop that takes elements of the electronic health record as well as the data collected by the community health workers to help create a new risk stratification model that will build from the practice out rather than try to graft an external model – or multiple external models – onto the clinic's data. Initially, Rust said, the data will likely contain common elements such as ICD codes and existing co-morbidity scores, but because that data will come from inside the MSM practice, it may be more accurate than claims data from an insurer.

"More importantly, we can do the next step, which is once we have categorized people as high risk or medium risk, we can use the ongoing EHR information to create a surveillance map,” he said. “For example, if somebody's been classified as being at medium risk, they may receive occasional phone calls, but if they come in and their blood pressure pops in over 180 or their A1c pops in over 9, they'll be pushed up on a temporary basis into the high-touch level, and we'll do a little bit of intensive contact for a while."

Rust said the cash portion of the grant has been mainly earmarked for the additional staffing;  the in-kind technological contribution from Optum will be used to create the data feedback loop, particularly the dashboard interfaces and tools the nurse-manager and community health workers will use.

The dashboard is envisioned as the front end of a system that will allow the care manager to be able to call up a screen every day and see different demographics, such as how the whole panel is doing, or how the top 20 high-risk patients are doing, as well as new alerts.

"We're trying to figure out what that user interface looks like, and keeping it refreshed so it's actually doing surveillance, to create new opportunities for intervention," Rust said. "And it's not just Optum creating something and giving it to us. There will be some back and forth in the design of those interfaces."

The project will also be technology-agnostic in terms of patient engagement. While a recent study from Northwestern University theorized that patient portals can actually exacerbate existing disparities in care, Rust said Morehouse's long-standing relationship of trust with the community the project is intended to serve will be a vital foundation for however those people wish to communicate with their caregivers.

"You have to have the human connection first, that relational trust is the key element, and then you look for the tools that will support that," he said. "If you can make the human connection with people through the community health worker, then you can identify their preferred form of communication. We do have a web portal and some people like to use that. Others will want text messages or cell phone calls. Others will say 'I want to be private but I'll come to group meetings in the church basement.' So the key is to balance high tech and high touch and to offer a menu of options that follows patent preferences."

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