Five Fundamentals for Effective Care

In our continuing exploration of innovative models of care, in this blog we will examine the efforts of the Cambridge Health Alliance (CHA) to advance primary care in the context of a diverse and vulnerable urban population. Located in the Boston area where it has served as a laboratory for testing innovations in care, the CHA has evolved into a model that integrates the physical, mental and social needs of its patients.  Much of the work to date is described in their “Guide and Toolkit”.

Incorporating the concepts discussed in our September 9th blog, the Alliance has developed a carefully constructed team approach to care. With the team at its core, the CHA model includes four other foundational components:

1. Incorporation of non-licensed, culturally competent community members.
2. Focus on Health Literacy.
3. Integration of mental health and social health into primary care.
4. Care Management for both routine and complex patients.

With the triple aim as a guiding light, CHA has a sophisticated approach to mass customization of its services to meet the overall needs of each patient. The alliance has gone to great lengths defining the team and defining roles and responsibilities for 12 different team members, from providers and nurses, to volunteer health advisors and community resource specialists. They have also developed logistical guidelines to  ensure optimal patient engagement and outcomes, as well as efficient and effective use of resources.  

Building on the concept of a core team that focuses holistic engagement with each patient, the alliance has built robust capabilities in population health and care management, enabling the integration of behavioral health and social determinants of health into the care environment.
In population health, the alliance incorporated a data and reporting structure that makes it easy for care management staff to identify, prioritize and develop care plans for patients in need. 

Leveraging this information, the alliance has developed two levels of care management.  Within each care team routine care management is provided by a variety of team members depending on each patient’s needs in the realm of mental health, medical frailty or complexity, and social instability. For the most vulnerable patients, there is a complex care management team that both takes referrals from the care teams and does primary outreach to patients identified through its population health reports. The complex care management team has dedicated nurses and social workers that spend 100% of their time supporting those patients. 

Having established a high functioning core, the alliance has been able to incorporate a variety of capabilities into its team approach. One example is the Oral Physician Program in which dental residents were brought in and trained to incorporate primary care preventive services into their routine oral care practice. In addition, the alliance fully integrated pharmacists and nutritionists into the practice to expand its capacity to meet the acute, chronic, and preventive care needs of patients.  

Beyond the integration of licensed professionals the incorporation of unlicensed, culturally competent community members has proven to be a cost effective way to expand the healthcare team’s capacity and effectiveness.  By providing outreach, improving health literacy, and building trust, these staff members have been able to drive measurable improvement in chronic care outcomes and patient satisfaction.

For practices serving the most vulnerable populations in their community, there is much to be learned from the ongoing work of the CHA. By fully committing to the team approach to care the alliance has successfully created a model that is accessible, efficient and effective in meeting the needs of a diverse and vulnerable urban population.