SMHCVH implemented the PHT in 2017, building upon an established patient-centered medical home team that included CDEs and nurse care managers. Between 2017 and 2021, the PHT expanded upon existing roles and includes 3 registered nurses involved in CCM and other clinical services, 2 clinical dietitians, 6 CHWs, 2 CDEs, 3 behavioral health therapists, and a population health director.
CCM at SMHCVH relies on the essential elements of the Chronic Care Model (e.g., community resources, health system, self-management support, delivery system design, decision support, clinical information systems) to provide care coordination and medical case management to patients, especially for those with multiple chronic conditions. In addition to direct support from CDEs and CCM nurses, SMHCVH CHWs offer community-based chronic disease self-management and chronic pain self-management sessions based on the Stanford self-management program curricula.11 (link),12 (link)The PHT sustained existing CDEs and offered individual DSME and group chronic disease education programs. CHWs conduct outreach through one-on-one visits or community-wide events and are conduits to other PHT services.13 ,14 The IBH model at SMHCVH integrates behavioral health providers directly into primary care clinics, and PHT team members provide warm hand-offs to ensure patient preferences and concerns are considered. Registered dietitians improve the integration of Medical Nutrition Therapy into existing diabetes education. The dietitians work directly with patients, providers, and community partners to support both patient-level and population-level nutrition goals.
CCM at SMHCVH relies on the essential elements of the Chronic Care Model (e.g., community resources, health system, self-management support, delivery system design, decision support, clinical information systems) to provide care coordination and medical case management to patients, especially for those with multiple chronic conditions. In addition to direct support from CDEs and CCM nurses, SMHCVH CHWs offer community-based chronic disease self-management and chronic pain self-management sessions based on the Stanford self-management program curricula.11 (link),12 (link)The PHT sustained existing CDEs and offered individual DSME and group chronic disease education programs. CHWs conduct outreach through one-on-one visits or community-wide events and are conduits to other PHT services.13 ,14 The IBH model at SMHCVH integrates behavioral health providers directly into primary care clinics, and PHT team members provide warm hand-offs to ensure patient preferences and concerns are considered. Registered dietitians improve the integration of Medical Nutrition Therapy into existing diabetes education. The dietitians work directly with patients, providers, and community partners to support both patient-level and population-level nutrition goals.
