Primary Care Health Home: Where the Heart Is

Mary Patterson-Lawson, L.P.N., Patient Care Coordinator, left, meets with Melanie Chaffin, R.N., Nurse Care Manager, about providing social services for a Primary Care Health Home primary care patient.

Every month, more than 700 patients participate in Swope Health Services’ “Primary Care Health Home” program for primary care.

What is a Primary Care Health Home?

“It means we are the home for our participants to receive their healthcare and assistance with managing their chronic diseases,” said Brittney Hazley, SHS Health Care Home Director. “It’s like having a family member inside SHS.”

The program is open to anyone insured under MO HealthNet, Missouri’s Medicaid program, who have certain diagnoses.

A diagnosis of obesity or diabetes will qualify, as will a combination of any of the following: hypertension, anxiety, depression, tobacco use, asthma or any cardiovascular disease.

The purpose of the program is to help patients live healthier lives, Brittney said.

“We want to understand the patient’s situation so we can find out what they need and provide resources to help,” said Brittney.

That help might include arranging transportation, scheduling appointments, assisting with referrals to specialists, obtaining medical records and coordinating care within and outside of SHS.

Care coordination is an important part of the Primary Care Health Home program. Here Natalie Myer, R.N., consults with Susan Livengood, M.S.N, R.N., to make sure a patient’s healthcare records are up to date.

The services can include education about chronic conditions for the patient and family, as well as support from a nutritionist, diabetic education program, tobacco cessation program and behavioral health programs.

“We’ll do whatever we can to help the patient take ownership of their healthcare,” Brittney said. “We want patients to be empowered to take control of their health.”

The National Committee on Quality Assurance, a private not-for-profit organization, reports the program is working. In Missouri, rates of hospitalization and emergency room visits have declined by 14 percent and 19 percent, respectively, for patients in the program, and patients are demonstrating better management of their chronic conditions.

For example, between 2012 and 2015, the percentage of patients with diabetes who had controlled blood glucose levels increased to 61 percent, from 18 percent, according to a report on Missouri healthcare homes.

SHS has offered the program since 2012 and is now planning to expand the initiative to its satellite clinics. Once patients enroll in the program, they are encouraged to stay in touch at least monthly with their care team, which includes three Nurse Care Managers, a Patient Care Coordinator, a Behavioral Health Consultant and the Director.

“We work on building rapport and trust,” said Brittney. “We want to make it easier for our patients to manage their chronic conditions.”