Poster 128: Health Care Home: Back to the Future

Abstract

Objective: To describe a model of health care home services for persons with physical disabilities and complex health conditions. Design: Short cycle outcomes analysis. Setting: Freestanding medical clinic, including primary care clinic, rehabilitation, and psychiatric services. Participants: Persons with disabilities aged 18 to 65 with public or private health plans. Interventions: Primary medical care coordinated through care plans, clinical pathways, prioritization of secondary conditions, short cycle process improvement, patient engagement, communication with other medical and social supports, and alternatives to clinic visits. Main Outcome Measures: Healthy Days, Secondary Conditions Surveillance Instrument, PHQ-9, Satisfaction Surveys. Results: Clients are highly satisfied with clinic services. Reimbursement business model is challenging, can be influenced by client acuity and payer mix. Review of outcomes data refined clinic services to minimize the effect of secondary conditions on self-reported overall health of clients. Short cycle review of care pathways for 7 common conditions (depression, seizures, hypertension, pneumonia, urinary tract infection, wounds, and diabetes) focused on the progression through the pathway, and the interactions of conditions. Cost-savings demonstrated in avoidance of hospitalization and readmissions, based on previous client history. Cost savings demonstrated through the use of telemedicine and phone monitoring to manage chronic conditions. Conclusions: While cost savings have been demonstrated through a strong primary care model, focusing on hospitalization and readmission prevention, cost savings to the overall system remain uncertain. This client centered model of care, incorporating coordination of medical and social supports, has potential to effectively meet client needs.