In the first year, CAP-NM worked on establishing and sustaining an integrated health care delivery system across provider organizations to expand access and services for the uninsured and underinsured in Bernalillo, Sandoval, Torrance and Valencia counties.
The program has developed the concept of a "health commons" in which a variety of health and social services are located at a single clinical site ("one stop shopping"), bringing needed resources to local communities.
Clinics have undergone redesign processes to increase efficiencies, and to increase clinic capacity to see more patients with the same resources. Utilizing web-based technology, CAP-NM has created an Extranet system which allows sharing of patient information between previously incompatible MIS systems in order to share vital client information, eligibility determination, availability of primary care appointment slots, referrals, and consultative reports for safety net providers.
A major success has been the development of a "Primary Care Dispatch" project, which was implemented to address the crisis of over crowded emergency rooms and too few hospital beds. Emergency departments nationally are overcrowded, often on divert status, and treat patients who could more appropriately be seen in primary care settings.
Now, patients being discharged from the University Hospital ER, without a primary care home can be scheduled from the ER, 24/7, for timely follow-up appointments at participating CAP-NM provider systems. Patients are assigned to a clinic in their home neighborhood, where they establish their own PCP in a new "primary care home." To date, more than 150 patients have been scheduled, with greater than a 70% show rate to their follow up appointments.
Plans for Year 2
Data shows that for indigent patients who are very high consumers of health resources, 70% of the underlying causes of their medical problems are social/behavioral, and 70% of the social/behavioral problems involve alcohol and substance abuse.
With added assistance from the McCune Foundation, CAP-NM is helping link a variety of social agencies with CAP providers and with the private community to form a broader, Coordinated Systems of Care (CSC). Building upon this broad, community coalition of services, a model of care has been adapted from the Coordinated Care Network of Pittsburgh, a sister CAP program.
Primary care/behavioral health/case management teams will be established to identify and track high users in our systems and to determine which community resources should be mobilized for those users. CSC will train and employ community/lay health workers in partner systems, who will be prepared with skills in basic case management and behavioral health and who will serve as clinic and case management extenders into the community and homes of the neediest clients. In partnership with New Mexico's Medicaid Salud! Managed Care Organizations, CSC will evaluate whether its intensive, community-based case management and its access to a variety of health and social services can reduce the cost and improve the quality of care for a very high users in the Medicaid population.]
Lessons learned from the expanded health and social service partnerships developed through this major CAP-NM grant are being shared statewide and nationally.<p.
Contact: Cindy Foster, 272-3322