Primary Care Projects: Care Coordination

Project Description

Fort Bend County received approval to develop a project where uninsured/ under-insured population (Indigent Health Care), Medicaid patients who are frequent and/or inappropriate users of the County Emergency Medical Service (EMS) and hospital Emergency Departments (EDs) or who have repeat admissions to the hospital within a short period of time, will be referred into a Care Coordination (patient navigation) system based in the local Federally Qualified Health Center (FQHC). 

Care coordination will include:

  • Assistance with making and keeping outpatient appointments
  • Assistance with medication needs and medication compliance
  • Appropriate case management of chronic conditions
  • Dietary and exercise education
  • Transportation if needed
  • Connection to Social Service agencies for other needs

The Care Coordination program will be housed within the local Federally Qualified Health Center (FQHC), AccessHealth, formerly Fort Bend Family Health Center. This FQHC provides preventive care, management of chronic conditions and treatment of outpatient acute illnesses to patients. AcessHealth will become the medical home for patients referred to and cared for at the facility.

Goals and Relationship to Regional Goals
The goal of this project is to provide a coordinated program of referrals, care management, patient centered needs resolution, community to medical home connection, and evaluation of program success in a rapid cycle improvement method. The project will add community health worker capacity to the local FQHC and provide payment for services provided to those without means or coverage to pay.

The goals include:

  • Reduction in use of high end medical resources such as EMS and EDs
  • Increase in the number of medically indigent, uninsured, and Medicaid eligible clients who have a medical home, prevention services and chronic disease management

The project addresses the following regional goals:

  • Increase access to primary and specialty care services, with a focus on underserved populations, to ensure patients receive the most appropriate care for their condition, regardless of where they live or their ability to pay.
  • Transform health care delivery from a disease-focused model of episodic care to a patient-centered, coordinated delivery model that improves patient satisfaction and health outcomes, reduces unnecessary or duplicative services, and builds on the accomplishments of our existing health care system.

5-year Expected Outcome for Provider and Patients
Through better utilization of medical homes for community members who presently receive episodic care in our emergency departments, Fort Bend County expects to achieve improvements in the health status of the targeted population, better utilization of available community resources and decreased use of high cost emergency departments and EMS for non-urgent health conditions.

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