Integrating and sustaining patient navigators in a primary care medical home

Wednesday, June 1, 2016: 8:00 AM-9:30 AM
Broadway II (Hilton Portland)
In 2012, Multnomah County Oregon Health Department's HIV Health Services Center (HHSC) was one of nine demonstration sites across the nation awarded HRSA Special Projects of National Significance funding to integrate patient navigators (community health workers) into its Patient Centered Medical Home. HHSC formed a collaborative partnership with Cascade AIDS Project (CAP), the oldest and largest community-based provider of HIV services, housing, education and advocacy in Oregon and Southwest Washington. In an innovative approach, the navigators are imbedded in a multi-disciplinary team at HHSC. They participate in client advisory board and building better care (quality improvement) meetings; attend morning huddles with medical providers and case managers; and document work with consumers in patient electronic medical records. The patient navigators at HHSC/CAP work with HIV positive patients who lack homes or are unstably housed and struggling with behavioral health and/or substance abuse to obtain housing, critical support services and medical care. Outcome measures include viral load suppression; primary and behavioral health visits; quality of care; housing and medical case management visits; perceived stigma; health related quality of life; housing status; and patient quality of care measures. Presenters will describe the training and integration of patient navigators into a PCMH setting; developing partnerships with community housing and social service agencies; the role of the patient navigators in identifying and engaging patients in medical care and assisting them to obtain stable housing; program outcomes tracking and evaluation; successes and challenges of inter-agency collaboration; and strategies to sustain navigation programs once grant funding has ended.
Maurice Evans (SPNS Navigator Team Lead, Cascade AIDS Project)
Christa Black, MPH (Project Manager, Multnomah County Health Department)
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