Grace’s care team includes a nurse practitioner and social worker who work together to provide ongoing home visits and patient support. In addition to monitoring patients’ health, they help identify and connect them with community services that can address housing, food security and other needs. Grace home primary care also educate patients and their caregivers on how to best manage their condition. This approach helps them reduce emergency department visits and hospital admissions.
What type of doctor is best for primary care?
This innovative approach to home-based primary care aims to improve outcomes for vulnerable populations, such as seniors and people with chronic diseases, while reducing costs to the healthcare system. The GRACE model augments PCMH by incorporating four proactive, continuous processes (comprehensive assessment; evidence-based care planning and monitoring; promotion of patients’ and their family caregivers’ active engagement in the management of their own health; coordination of professionals involved in the patients’ care).
A dedicated social worker helps clients with their mental health and social issues, such as accessing community resources or finding guardianship assistance. A mental health liaison also supports the NP/SW dyad by assisting with accessing clients’ mental health records and ensuring that the primary care provider is aware of their treatment history.
In order to address the challenge of providing specialist care to many of their uninsured patients, Grace created a Care Coordination Department to facilitate all referrals and ensure that community specialists had access to necessary information for their evaluation and treatment. This approach helped Grace satisfy PCMH element 3C, support self-care process, by coordinating with these community specialists to develop and implement a care plan for each patient.