By Melinda Young
A federally qualified health center partnered with community organizations to improve the population’s overall well-being, including the elderly.
- The future of healthcare might be to think more like case managers and focus on social determinants of health.
- Partnerships with food banks and other groups can help a provider group care for patients more effectively and efficiently.
- Programs include group art therapy that can be provided in Spanish and assimilated to virtual sessions during the pandemic.
Just as it takes a village to raise a child, it takes a village to care for an elder.
With this philosophy in mind, a community health center in California has partnered with various local organizations to better serve its growing elderly patient population. Partners include food banks and other healthcare organizations involved with the Program of All-Inclusive Care for the Elderly (PACE).1
“Healthcare has become so incredibly complex, and there are so many different components to it that no one entity can do everything,” says Marie Russell, MD, MPH, chief medical officer and chief operations officer at TrueCare in San Marcos, CA. “What we’ve learned from the pandemic is that healthcare is really about a village. The system cannot operate in a silo.”
Healthcare organizations should think more like case managers. When considering a patient’s health, they should see the whole picture of what is preventing someone from making the best health choices. This also works to improve population health.
“We have both centralized case management and decentralized care coordination,” Russell notes.
Provider teams include health educators, nurses, and care coordination. “We have case management to ensure timely and adequate follow-up for abnormal breast screenings or colorectal cancer screenings,” Russell explains. “Right now, a lot of follow-up is done by phone or video.”
Preventive Care Is Key
It also is important for providers to use their resources to help patients overcome barriers and to improve overall community health. Partnerships with local organizations allow providers to care for their communities more effectively and efficiently.
“Our role as primary care providers and a safety net is to really ensure the health of the patients we serve is being proactively addressed,” Russell says. “It’s all about prevention.”
TrueCare, a federally qualified health center (FQHC), provides medical, dental, and behavioral healthcare. They also provide lab, X-ray, and pharmacy services through 11 locations and mobile units.
“We participate in California’s Enhanced Care Management [Medi-Cal benefit],” Russell explains. “Essentially, it is serving case management of high-risk individuals who are complex medical or older people.”
Case managers identify the needs of high-risk patients and connect them to appropriate care. “TrueCare is a community health center that is dedicated to population health and dedicated to the community,” Russell says. “Our primary focus is the delivery of clinical care.”
The center serves all ages with primary care services, family practice, pediatrics, behavioral health services, dental care, and a chiropractor. Through community partnerships, the organization also provides information or hands-on help with rental assistance, youth services, an agricultural health program, food distribution, and a money-saving electricity program.2 The organization also offers a program called Golden Years, which is specifically geared toward older patients.
“As we look across the population and our demographics, we know baby boomers are coming of age, and our senior population is growing,” Russell says. “We looked for the opportunity to partner with a community health clinic that has PACE, which tries to [serve] individuals who are 55 years and older, and who would otherwise qualify to be placed in a skilled nursing facility, within their home in the community.”
Seniors who qualify for Medicare/Medicaid’s PACE can keep their primary care providers at TrueCare, but they also can benefit from PACE programs. “The things we can’t do because we focus on clinical care, our patients can get through the program,” Russell says.
TrueCare is more than 50 years old, and some of its relationships have existed a long time, says Cheryl McMahen, MPA, director of community engagement. Pediatrics is one of the organization’s priorities. Collective opportunities can help this population, she notes. (For more information, see story in this issue on collaborations that help pediatric patients.)
Support for Seniors in Golden Years
One of the more successful programs is the Golden Years social support group for Spanish-speaking patients. There are some long-time members, and the group continually welcomes new patients. “We’ve received an amazing number of testimonials from people about how engaged they are,” McMahen says. “The support groups were done in person, and then the pandemic happened. We took a hiatus, and were unable [at first] to facilitate the meetings with this senior, vulnerable population.”
Over time, the program moved to virtual meetings. “We created opportunities through a virtual learning platform,” McMahen says. “We also have an art therapist, who is a licensed behavioral health professional, to provide group art therapy.”
TrueCare provided tablets to people who could not access the virtual meetings with their own devices. Soon, everyone could see each other’s faces and interact.
“We get supplies mailed out or dropped off to members for everything they need,” McMahen says. “The art therapist comes once a month.”
Support group members work on crafts, paintings, or an activity, and then they talk through it. One project was a vision board for seniors, and they talked about their feelings and what their lives are.
“We ask them questions about things that, a lot of time, people don’t discuss with them,” McMahen adds. “One thing they love is we’ve taken this time to invest in their mental health and their need to interact with others.”
When a new member joins, everyone makes the person feel welcome. Group members take pride in showing their artwork to one another. “They’re a wonderful group, and they have a lot of gratitude, which we appreciate,” McMahen says. “It’s important they have this community and can lean on one another. These are individuals who will be friends for life.”
Mobile Units Provide Care
TrueCare received a matching grant to provide mobile services in two counties. The goal is to reach more people in an underserved population. The organization will use three mobile units to bring clinical and dental services to communities.
“We serve agricultural workers, and some are not able to travel to where we are,” Russell explains. “We bring the mobile units to them and to schools to help with school-based programs.”
The mobile units include a medical team, a dentist, a driver, and medical assistance staff. “The provider would communicate with case management staff or care coordination staff to make sure any care coordination is done,” Russell says. “We have used the mobile unit to address COVID surges, and we have nurses who can do testing or COVID vaccinations with the mobile unit.”
Healthcare organizations that expand their outreach through mobile units can raise funds through donations and philanthropy for this expansion. “Bringing care into the community is inspirational, and donors can get behind it,” Russell says. “The visits are billable to Medicaid, so there is a revenue stream associated with it. But, more importantly, it is a commitment to the community health center to provide care in the community, and we rely on revenue from visits and generous donors to do that.”
The collaborative care model at TrueCare is all-inclusive, holistic care. “In the healthcare world, we’ve been talking about it on a regular basis,” McMahen explains. “There is high need, but there are a lot of resources. It’s about coordinating it and bringing it together.”
One way to look at care coordination and collaboration is to think of the concept of collective impact. Case managers already do this when they identify patients’ social determinants of health and find resources to help patients with housing, transportation, food, and other issues that affect their health. “You can take all of these resources and organizations and put everybody together,” McMahen says.
The goal is to avoid duplicating efforts and to organize around the central goal of finding resources and support for patients.
“You have priorities and the things you are working on, and so do the other partners. But it’s the common goal of helping the community,” McMahen explains. “The concept I’ve learned is called collective impact, which is taking multiple groups and bringing them together.”
Ultimately, healthcare is about partnerships. “We’re all in it to improve the health of the communities,” Russell adds.
- PACE. Medicare.gov.
- TrueCare San Diego Community Programs. 2022.