CTuJ1 - Extending the Reach of Community Health Centers into the Home: Early Learnings from Two In-Home Primary Care Pilots

Session Description: Community Care Cooperative (C3) is an Accountable Care Organization governed by Federally Quality Health Centers (FQHCs). As C3 supports their health centers in the move towards value-based care, there is significant interest in developing and testing new models of care that move away from the existing model of 15-20 minute visits for all patients, regardless of patient need or complexity.

In this session, we describe the design and implementation of two concurrent in-home primary care pilots at two community health centers, the Community Health Center of Cape Cod and Greater Lawrence Family Health Center. The pilots are designed to engage a subset of patients whose needs cannot be effectively met in ambulatory settings due to a combination of medical fragility, chronic condition burden, physical disabilities, and/or behavioral health conditions by bringing primary care services directly into the home. One pilot program is staffed by a team of health center clinicians and the other pilot program is staffed by a community-based clinical partner, Feltin Community Care, in close collaboration with the health center team.

We describe how we leveraged C3’s claims database to identify potential patients based on key utilization and clinical indicators. In addition, we share how both pilot programs collaborate with the health center care teams to engage and coordinate care for these complex patients. We share lessons learned in the program design and implementation, patient and provider feedback, characteristics of the intervention population, and early insight into the impact on utilization and patient outcomes.