Tags: coordinated care , redesigning care

One year ago, the Southern Jamaica Plain Health Center (SJPHC) received a 2-year Partnership for Community Health Excellence and Innovation grant that helped create two new, critical roles: a medical social worker and a health coach.

The grant, one of several awarded by organizations that make up the Partnership for Community Health—Neighborhood Health Plan (NHP), Partners HealthCare, and the Massachusetts League of Community Health Centers—is designed to foster innovation and enable the redesign of care at community health centers (CHC) that are working to redesign service delivery to improve the patient experience and to provide higher quality, timely access to care.

Tom Kieffer, Executive Director at SJPHC, said the roles have filled a real, specialized need, and the results are already speaking for themselves. “Often physicians and other providers would get bogged down with time consuming tasks that they were either too busy to address, or not skilled to complete, and the patients would not end up getting the safest set of services they needed,” Kieffer said.

The best care we can provide is to address a patient’s needs in the moment, and to bring in a member of the team with the time and knowledge to work through every issue.

Having these positions at SJPHC is especially important because the patients they serve are often living with a range of complex and debilitating chronic health issues, including dementia, diabetes, and hypertension. These conditions can be further compounded by language or cultural barriers, which may hinder medication adherence and scheduling follow-up appointments.

Navigating these complexities is where the health coach shines, says Cindy Engler, project manager at SJPHC. The coach works directly with patients on everything from simple reminder calls about upcoming appointments to imperative medication reviews that help track dosage adherence and ensure that patients are taking medication as prescribed by their doctor, but it doesn’t end there. “The health coach is bilingual and bicultural, and can sit with the patient and set treatment goals, which is especially important when treating hypertension and diabetes,” she said.

This added layer of trust allows the coach to create a care plan with the patient, foster a relationship, and encourage them to meet their goals.

 “This was all work that physicians were doing,” Kieffer said. “Talking goals, overcoming communication barriers, troubleshooting—they were equipped to have these conversations, but they simply did not have the time to do it effectively.”

The coordination of integral quality care services that occur outside of SJPHC are also the responsibility of the medical social worker. This includes certain referrals, re-engaging the patient in behavioral health counseling, and psychiatric services.

“The medical social worker motivates the patient and assesses them. Many of these patients are upset or concerned about a treatment or appointment that they haven’t been able to get done. This is not a situation where the physician can address their needs alone,” Kieffer said.

Engler says that measurable data about the impact of these two positions won’t arrive until 2017, but early success stories and a confidential survey of patients from the past year have been encouraging. According to the survey, 100% of respondents reported that they felt “supported” during their experience with SJPHC, and an impressive 85% felt “extremely supported.”

Overall, the SJPHC staff is optimistic and excited about the future. With still more than a year’s worth of grant funding remaining, they hope to continue to build on the accomplishments achieved so far.

“So far, this has been an exciting project that’s shown a real impact on the quality of care we provide,” Kieffer said. “The best care we can provide is to address a patient’s needs in the moment, and to bring in a member of the team with the time and knowledge to work through every issue.”