2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Supporting Vulnerable Populations: A Model That Can Make a Difference

In an increasingly complex and competitive healthcare environment, ensuring access to integrated care for our most vulnerable populations is becoming evermore challenging. Metro Community Health Centers (MCHC) has embraced this challenge and is providing patient-centered services designed specfically for patients with complex needs. MCHC is a Network of five Federally Qualified Health Centers (FQHCs) providing comprehensive healthcare services to a culturally diverse, underserved, and often medically and behaviorally complex patient population throughout NYC. MCHC’s team-based model of care includes primary and specialty care, behavioral health, dentistry, and rehabilitation services that are grounded in practices that empower and support each patient’s physical, mental and social well-being. A significant number of our patients have intellectual/developmental disabilities (I/DD), and while some challenges to obtaining optimal health are unique to this group, many are concerns that are also seen in other vulnerable populations:

  • Research shows that vulnerable populations, including the economically disadvantaged, racial and ethnic minorities, uninsured, and those with I/DD, experience inadequate access to care, poor receipt of health care services, and ultimately poorer health outcomes (Hayden, M.F, Kim, S.H., DePaepe, P., 2005, Krahn, G.L., Hammond, L. & Turner, A., 2006, Shui, L, & Stevens, G.D, 2005).
  • Compared with other groups, vulnerable populations are also more likely to experience earlier onset of illness, greater severity of disease and more preventable mortality (Havercamp, S.M., Scandlin, D. & Roth, M., 2004, Wilson, P.M., Goodman, C., 2011), and preventable mortality (Havercamp, S.M., Scandlin, D. & Roth, M.,2004, Horowitz SM, Kerker BD, Owens PL, Zigler E., 2000, Williams, D.R, Mohammed, S.A, Leavell, J., & Collins, C., 2012).
  • Low socioeconomic status groups and individuals with I/DD often struggle with risk factors associated with chronic conditions including poor nutrition, obesity, and sedentary lifestyles (Rimmer, J., & Hsieh, K., 2011, Pampel, F.C., Krueger, P.M. & Denney, J.T., 2010).
  • Although at greater risk for chronic diseases, they often have less access to appropriate health care services, and prevention services are rarely implemented with this population. (Anderson, L.L., Humphries, K., McDermott, S., Marks, B., Sisirak, J. & Larson, S., 2013., U.S. Public Health Service, 2002).

Compounding these issues is a limited number of healthcare professionals qualified and trained to meet the specialized needs of this population, and a lack of continuity in care. In addition, many health centers lack the specialized equipment and supplies needed to accommodate a wide range of patient function and ability. This creates significant access problems for vulnerable/complex needs populations.

Maintaining continuity in care is also a critical component of quality healthcare for vulnerable populations. However, obtaining continuity across multiple service systems is challenging. Many primary care providers do not provide or have ready access to adequate case management services. They often focus on the medical issues at hand and overlook the preventative and social needs of the patient. Limited knowledge of resources available can also leads to poor continuity in care.

Some key indicators of effective and sustainable care for under-served patients with complex needs, include: (1) Integrated Care, especially Primary Care and Behavioral Health; (2) Accountable Care; (3) Holistic Care; (4) Strategic Partnerships; (4) Community Engagement; and (5) Robust Health Information Systems.

There are many other components that provide value to a patient’s care, but these components, coupled with reliable and fair revenue streams (big surprise!), can truly make a difference. MCHC’s approach to care, grounded in access for patients of all abilities, starts with a key foundation – the Patient Centered Medical Home (PCMH). The National Committee for Quality Assurance (NCQA) has recognized MCHC as a Level 3 PCMH. A growing body of evidence demonstrates that Medical Homes improve quality of care, health outcomes and patient satisfaction, while reducing health disparities, hospital and emergency room visits and overall costs. An array of on-site services provided under the direction of a diverse team of primary and specialty care providers enables holistic delivery of quality care.

In addition to developing a holistic model of health care for underserved and vulnerable patient groups, MCHC also recognized the value in working with a larger group of providers to meet quality of care objectives and reduce costs. MCHC is a founding member of the Alliance for Integrated Care of New York (AICNY). AICNY is a unique, state-wide Medicare Shared Savings Program Accountable Care Organization comprised of clinical partner organizations that support 6,000 vulnerable patients across NYS. Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors (Centers for Medicaid & Medicare Services, 2015). Clinical and community partnerships are essential in meeting these goals, especially when coordinating care for vulnerable populations who often require a range of services from multiple providers. Unlike many ACOs in New York over the past year or two, AICNY has been successful in reducing the cost of care while achieving high quality scores on standardized clinical care measures. Because we have strong healthcare data analytics available to our team, we are able to specifically track patient service utilization, cost, diagnoses and procedures and risk-stratify patients to help inform our care planning.

MCHC is a growing FQHC network in large part because we have committed to serving a complex patient population that the general medical community is often not prepared to treat. Cerebral Palsy Associations of New York State recognized this when they planned and successfully spun-off MCHC as an independently governed and managed organization in August of 2015. HeartShare Human Services of New York also recognized the potential of a network of this kind, and consolidated their Downtown Brooklyn Health Center into MCHC’s network in August of 2016. Strengthening the network even further, NYU Lutheran Family Health Centers provided robust support for MCHC’s designation as Federally Qualified Health Centers. The strengthened partnerships and collective strategic and visionary planning of these organizations resulted in an expanded scope of community healthcare and a reinforced commitment to a sustainable healthcare system for patients with complex needs.

MCHC’s healthcare network, specializing in the care of individuals with I/DD, among others, is now among the largest FQHC systems in the nation with a focus on this population. Other vulnerable populations can benefit from a strategic model of care such as the one we have pursued. Providing access to primary, specialty, behavioral and dental services in our health centers ensures improved access, efficiency and coordination of care for underserved and vulnerable patients. MCHC staff is experienced in working with patients with complex needs and is committed to treating patients and their families and support networks with dignity, professionalism and sensitivity. Our team is always seeking out new partners with whom we can strengthen community-based systems of care for those most in need. Now, more than ever, successful partnerships make and keep healthcare organizations strong and vibrant as we all seek new opportunities and navigate rough waters together.

Marco Damiani is Chief Executive Officer of Metro Community Health Centers, Inc., Chairman of the Alliance for Integrated Care of New York, LLC. and Chair of the Manhattan Developmental Disabilities Council.

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