medicalhome.102382331Community-based primary care is essential for sustaining and improving health.  Community health centers, free and charitable clinics, and primary care practices are at the center of community efforts to improve health and control costs.  At Community Health Solutions we provide a menu of supports to help community primary care organizations build their capacity to serve patient populations with diverse health needs and socioeconomic challenges.  We help primary care organizations:

  1. Assess Community Health Needs
  2. Develop Patient-Centered Care Models
  3. Strengthen Clinical-Community Linkages
  4. Evaluate Patient Outcomes and Costs
  5. Demonstrate Community Value

1. Assess Community Health Needs

Primary care practices need data on community health to inform service planning and strategic planning.  At Community Health Solutions we have developed a unique portfolio of community indicators that primary care practices can use to identify needs at the state, city, county, and in some cases even the neighborhood level.  Our data resources include demographic trends, maternal and infant health indicators, chronic disease indicators, adult health risk indicators, child health risk indicators, hospital utilization indicators, and more.  We help primary care practices use community data and other sources of community insight to plan their services and develop their strategies for the future.

2. Develop Patient-Centered Care Models

A patient-centered care model can be defined as a model of care that is explicitly designed to optimize the health of patients based on their particular needs.  Examples of patient-centered care models include: Health promotion and wellness, patient centered medical home, chronic care models, integrated care models; and community-based care transitions models. Whatever the health care setting, the design of a patient-centered care model should be determined by the needs of the patient population along the continuum of care. Community Health Solutions provides research, consultation, and learning support to help primary care practices identify patient population needs and implement responsive care models.

3. Strengthen Clinical-Community Linkages

The health system is moving toward new modes of care in which primary care providers are expected to manage the health of defined populations.  As this occurs the lines are blurring between clinical care and community services, and the system is shifting toward patient-centered care models that integrate care across clinical and community settings.  These community care models require new kinds of clinical-community linkages to optimize services for defined populations such as children with special health care needs, adults with chronic conditions, and women with high risk pregnancies. Community Health Solutions provides research, consultation, and learning support to help primary care practices design and implement community care models.

4. Evaluate Patient Outcomes and Costs

Population health requires new approaches to quality improvement and impact evaluation.  For primary care practices as with other providers, the challenge lies in measuring quality, costs, and outcomes for defined groups of patients such as those enrolled in Medicaid.  This capability is necessary to optimize patient health and to assure that payment levels are aligned with costs.   Creating this capability requires collaboration across clinical and financial units of the organization.  Community Health Solutions provides research, consultation, and learning support to help primary care practices evaluate quality, costs, and outcomes for defined patient populations.

5. Conduct Data-Driven Policy Analysis

Primary care is highly influenced by public policy changes such as Medicaid and Medicare reform.  It is imperative to assure that public policies are defined and implemented in ways that support community health improvement.  Community Health Solutions helps primary care organization analyze impact of policy changes on patient populations, community populations, and the viability of primary care practice Our approach combines the insights of local stakeholders with innovative data models to produce community-specific impact assessments.   The results can help primary care practices formulate informed responses to policy changes.

6. Demonstrate Community Value

Primary care practices are being challenged to demonstrate the value of the services they provide for their patients and communities.   Community Health Solutions has developed a practical model called community value analysis for helping primary care practices define and communicate the value they deliver.  We support the model by providing training, data, tools, and technical assistance.  The results can be used to make the value case for primary care to public and private sector payers as well as public officials and community leaders.

To learn more about our support services for primary care practices, contact Caitlin Feller at or 804.673.0166.

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