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La Clínica de La Raza: Contra Costa Nursing Care Expansion Initiative

As health care reform presses providers to deliver better and more efficient care to individuals and populations, many health systems have turned to team-based care as part of the solution.

Team-based care enables each member of the health care team to optimize his or her strengths and training. This includes registered nurses (RNs) who, in addition to their clinical training are the health system’s care coordination experts. Care coordination leverages prevention and wellness programs and ensures patients move efficiently and appropriately from primary care to specialty care, hospitalization and back again. For Contra Costa County’s growing population of medically uninsured and underserved adults, this can be an especially daunting challenge.

With all of these factors in mind, La Clínica de La Raza is in the midst of a three-year plan of action to effectively integrate registered nurses into clinical care teams at its Monument, Pittsburg and Oakley clinics. The John Muir/Mt. Diablo Community Health Fund (CHF) is supporting this effort with separate grants of $250,000 for each of the three years.

La Clínica’s plan, titled the Contra Costa Nursing Care Expansion Initiative, aims to:

  • Expand the ability of La Clínica providers to see more patients, maximize the use of licensed staff (physicians, nurse practitioners and physician assistants), decrease the cost of care, and contribute to improved clinical outcomes, operational efficiency and overall patient satisfaction.
  • Increase coordination between local hospitals and La Clínica to decrease emergency room department use and hospital readmissions.
  • Prepare La Clínica for the impending shift in provider reimbursement procedures from fee-for-service to payments based on clinical outcomes.

In the first year (2014), La Clínica added one RN at each Contra Costa clinic. The RN assumed the role of basic medical triage that physicians, nurse practitioners and physician assistants were doing. La Clínica also developed data collection systems to track the results.

In addition, La Clínica worked on developing formal systems for coordinating care transitions from local hospitals to primary care, including drafting a Memorandum of Understanding (MOU) with one local hospital that was executed in 2015. That MOU enabled La Clínica, in year two, to test whether the new care transition systems can decrease emergency room department use and hospital readmissions. La Clínica also continued to develop internal care transition procedures for all it's Contra Costa clinics.

In 2016, La Clínica will use its final year of CHF funding to:  

  • Implement an internal care management transitions workflow system
  • Launch patient care management partnerships with a local hospital and Los Medanos College Nursing Program
  • Evaluate patient, provider and partner hospital satisfaction with the care transition program
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