La Clínica de La Raza: Contra Costa Coordinated Senior Health Care Delivery Initiative

Managing the health of older adults is typically quite complicated, because many suffer from multiple health concerns that can include everything from dental caries, gum disease, and hearing and vision loss to cognitive decline, depression, cancer, and heart and lung disease. Treating low-income seniors is even more complicated because they often struggle to get back and forth to provider visits and to effectively navigate an increasingly complicated health care system.

All of these factors make team-based care – which has been shown to improve health outcomes for many patients in many settings – especially promising for treating older adults. It can help them receive much of their care in fewer visits and ensure a more coordinated approach to helping them manage multiple health-related conditions.

Thus, after funding a six-month planning process, in 2012 the John Muir/Mt. Diablo Community Health Fund (CHF) provided a one-year, $350,000 grant to La Clínica de La Raza to launch its Contra Costa Coordinated Senior Health Care Delivery initiative to improve the health, well-being, and quality of life for more than 2,000 low-income, predominantly uninsured patients ages 56 and older.

The grant provided seed money to implement a number of system changes and build capacity. As a result, La Clínica established care coordination across medical, optical, dental, and behavioral health clinicians, as well as a variety of innovations to help frail seniors better address their health-related concerns. The initiative also helped prepare La Clínica for health system payment reforms aimed at changing reimbursement to promote efficiently delivered, higher quality health outcomes.

In 2013, the CHF provided an additional $250,000 to support a second year of implementation that focused on strengthening internal and external coordination of care for the highest risk seniors at La Clínica’s Concord, Pittsburg, and Oakley clinics. The funding supported institutionalization of staff training in geriatric care, increased links with others providing related senior services, a refinement of the software systems used to coordinate care, and a second-year program evaluation by Harder+Company.

The evaluation found that La Clínica:

  • Successfully reached high-risk seniors 56+ years, whose characteristics include general frailty, chronic health conditions (e.g. diabetes), difficulty managing medications, social and/or mental health challenges and difficulty attending scheduled appointments
  • Established Senior Care Managers who ensure high risk patients received intensive multidisciplinary services
  • Created Panel Management Assistants at the Monument Clinic to provide health coaching to these patients
  • Extended provider visits for high risk patients from 15 to 30 minutes
  • Created a High Risk Evaluation and Linkage Program, which facilitates meetings among interdisciplinary care teams for complex patient cases
  • Institutionalized dementia and general geriatric trainings for providers via Greenlight – La Clínica’s interactive training software system
  • Offers bi-weekly, Spanish-speaking diabetes management group meetings and monthly Spanish-speaking dementia support group meetings (in collaboration with the Alzheimer’s Association) at the Pittsburg clinic

The evaluation also found that La Clínica has developed both leadership and expertise around multidisciplinary care for high-risk seniors. Though CHF funding has concluded, the initiative continues to improve the health of frail, underserved seniors in central and east Contra Costa County.

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