Care Transformation Collaborative of Rhode Island: Building a Strong Foundation for Comprehensive, High-Quality...

Area of Science:

• Health Services Research
• Primary Care Models
• Healthcare Management

Background:

• The Patient Centered Medical Home (PCMH) model has limitations in achieving optimal cost and quality outcomes.
• Existing healthcare models require enhancement to address multifaceted patient needs.
• Recognition of the insufficiency of PCMH in meeting comprehensive health goals.

Purpose of the Study:

• To describe the evolution of comprehensive primary care in Rhode Island.
• To highlight the integration of behavioral health and social determinants of health (SDOH) into primary care.
• To present a model for addressing complex patient needs within primary care settings.

Main Methods:

• Systematic screening for behavioral health and SDOH needs.
• Dedicated care management for patients with complex conditions.
• Care coordination strategies to integrate services for identified needs.

Main Results:

• The evolving concept of comprehensive primary care in Rhode Island.
• Identification of critical patient needs beyond traditional medical care.
• Implementation of targeted interventions for behavioral health and SDOH.

Conclusions:

• Comprehensive primary care, integrating behavioral health and SDOH, is essential.
• Systematic screening and dedicated care management improve patient outcomes.
• Rhode Island's evolving model offers a framework for enhanced primary care delivery.