For further information contact: Karen P. Goldstein, kgoldst@peds.bsd.uchicago

1. Medical Home: Addressing non-medical issues by including non-clinic-funded partners in the Quality Improvement (QI) process Karen P. Goldstein, MD, MPH, MA, Assistant Professor of Pediatrics, University of Chicago, Pediatric Director, FFHC; Leah M. Durst, MD, Medical Director, FFHC; Amy Zimmerman, JD, Project Director, Chicago Medical-Legal Partnership for Children; James A. Mitchell, MA, Case Manager, FFHC; Emily Brice, BA, (former) Project Manager, Project HEALTH Help Desk A medical home is not a building, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective. In a medical home, a pediatric clinician works in partnership with the family/patient to assure that all of the medical and non-medical needs of the patient are met (Pediatrics 2002, 110, 184-6). Results: Improved Utilization and Referral Process Abstract CS3: Clinical Social and Support Services Objectives: Partner with community programs in the QI process to enhance coordination of the delivery of medical and non-medical care of patients and improve the overall health of patients. Target Population: Patients at a Federally Qualified Health Center on the South Side of Chicago serving primarily an African-American inner-city population with many psychosocial, financial, educational, legal,and community-related non-medical needs. • QI Subcommittee and collaborative partnership to improve coordination of non-medical services and quality of care. Subcommittee membership comprised of: • Health center staff: Medical Director, Social Worker, Case Managers, Nutritionist • University of Chicago faculty: Pediatric Director, Developmental-Behavioral pediatrician • Community partners: Project HEALTH Help Desk Coordinator, Chicago Medical Legal Partnership for Children Director • Steps Taken: • Clarified scope of services/expertise • Developed routing for referrals including those from multiple sites of service • Developed tracking of referrals by CS3 subcommittee chair • Provided feedback mechanism to referral source and chart • Created spreadsheet to tabulate referrals { • Results: • Single comprehensive CS3 referral form with all programs and scope of services listed • Referral procedures established and alternative action steps if provider is not available • Mechanisms for tabulation of referrals to monitor numbers and sources of referrals • Routing procedures and identification of responding program provider • Scheduled subcommittee meetings to address program development, coordination, problem articulation and monitoring of progress Goals Friend Family Health Center Community Partners • Establish a Clinical Social and Support Services subcommittee (CS3) as part of the larger health center QI process to promote the connection of essential non-medical services to the medical care of patients: • Identify and address personal, psychosocial, legal, community and health center barriers to health care • Improve coordination of non-medical services • Improve documentation of non-medical services in medical charts • Increase understanding and utilization of health center and community resources • Improve the overall health of patients and enhance their connection to the medical home • South Side Chicago Federally Qualified Health Center: • Internal and family medicine • pediatric and adolescent medicine • obstetrics-gynecology • social services (1 social worker and 4 case management) • nutritionist • on-site WIC program • Inner-city, primarily African-American, patient population: • 75% of the children/families are at or below the Federal poverty level • Community experiences high rates of: • underemployment/unemployment • crime • single-parent families • infant mortality rates • no prenatal care • Public health data documents poor outcomes on health status indicators (deaths from cancer, heart disease, incidence of diabetes, HIV, etc.) • Project HEALTH Help Desk • National not-for-profit organization that mobilizes college students to address the full range of psycho-social needs that impact a family's health and well-being. Multi-lingual undergraduate student volunteers receive extensive training on community issues/resources • Volunteers at entrance area of health center with banner listing range of services • Extensive computer database of community resources • Follow-up to assess adequacy and success with services provided and referrals to community/governmental resources Plans for the Future Chicago Medical-Legal Partnership for Children No cost legal assistance for low -income families (excluding criminal or malpractice cases) • On-site legal consultation-- attorney available one half-day per week at FFHC, by phone for emergency issues and as needed off-site for follow-up • Legal representation by Health & Disabilities Advocates, Legal Assistance Foundation and pro bono attorneys • Training of staff, social service personnel, health care providers and University of Chicago pediatric residents • Staff and provider review of services available • Introduction of combined referral form • Bimonthly CS3 meetings to continue QI process • Evaluation of referral processes • Feedback from health care providers and CS3 programs • Measurement of sources and types of referrals generated (comparison with prior CS3 program data and chart audits) • Review of findings from qualitative research project of health center users of CS3 services (K.Goldstein and T. Hamlish, pending) QI Process • Core committee oversees QI: • Systematic collection of data • Review data at monthly QI meetings • Identify current levels of performance/problems • Propose modifications • Identify resources/personnel responsible • Delineate action steps • Scheduled review of progress For further information contact: Karen P. Goldstein, kgoldst@peds.bsd.uchicago.edu Vanessa Askot Project HEALTH, Chicago@projecthealth.org Amy Zimmerman, CMLPC, azimmerman@hdadvocates.org