Accounting for culture in patient focused care

The Neighborhood Health Care Network and its affiliated Federally Qualified Health Centers, UCare (a local health plan), Hennepin County Medical Center, and the Minnesota Department of Human Services formed a partnership in 2005 to develop a more coordinated, cost-effective, and community-based care system approach to delivering health care for persons who face the greatest difficulty obtaining high-quality, culturally appropriate health care services. The Community Care Network (CCN) focuses on one of the most important areas of health care and health disparities today:  the treatment and coordination of care for people with chronic conditions, particularly those who are uninsured or underinsured.  The CCN takes the successful work of the national Health Disparities Collaboratives model to a new level:  going beyond specific clinic practices to an integrated system of care.  It seeks to connect key partners in the local health safety net so they are able to coordinate their services, share patient information, and meet recommended, evidence-based standards of care.  While the project initially focuses on people ages 18-64 with diabetes, we believe it has broad implications for improving the effectiveness and cost-efficiency of community health care generally.  

The CCN program provides enhanced care coordination and outreach services from Care Coordinators and Community Health Workers, incorporates psycho-social risk factors into the patient’s overall care plan, and provides financial incentives for achievement of patient self-management goals.  The CCN care model addresses self-management behavior and other psycho-social risks that can impact a person’s ability to manage his/her health care. A Life Style Overview tool (LSO), modified from a prenatal risk model developed by the City of Minneapolis, evaluates a patient’s risk for such factors as food insecurity, housing insecurity, transportation, social support, etc.  This program also investigates how the roles and functions of Care Coordinators and Community Health Workers impact the patients, the resources required to implement the model, and patients’ perceptions of value.  

The CCN program began recruiting members in June, 2007.  As of June, 2008, there are 250members in the CCN program, with additional members joining to a maximum of  300 total patients in this program.  Members include UCare enrollees with a diagnosis of diabetes, fee-for-service enrollees in Minnesota Health Care Programs (MA, GAMC, MnCare), and uninsured persons with an HgbA1c level of 8.5 or greater within the last 6 months.  Although initial implementation began slowly, continued provider and staff involvement and training has resulted in rapid expansion of patient referrals. 

Over the years, multiple challenges have been addressed.  An Implementation Team, comprised of members from all community partners, developed all standardized operational criteria.  Financial challenges were reduced because of the generous support of our UCare and the Minneapolis Foundation partners.  We are currently in the analysis phase of the program and have partnered with the University of Minnesota to assist with the analysis and program evaluation.  Preliminary data will be available in August, and the final evaluation is expected to be completed in January, 2009.