Collaborative Care Model for an Underserved Community Health Center

Community Population and Social Determinants of Health

The population of the area comprises mostly of African Americans. The community is a low-income area, and individuals who live here struggle to make ends meet. This makes it hard for them to access premium health care offered at private hospitals; therefore, most of them must rely on the community health center. Poor people have been associated with numerous chronic health problems that result from their lifestyles and a lack of viable income. The community is underserved in terms of social amenities. Additional structural challenges include reduced access to fresh foods, a high density of fast food restaurants, and an environment that is not conducive to physical activity. These conditions foster sedentary lifestyles that contribute to the development of chronic diseases.

Access to health care is limited, and the few who are able to reach the community health center must contend with substandard service. While the nurses and doctors who work in the facility mean well, a sheer lack of proper communication and role definition has made the services offered seem lackluster. With increasing numbers of obese community members, it is vital that the community receive appropriate health care, and health care professionals must be able to address the rising obesity rates.

A majority of community members do not have medical insurance and work irregular jobs; others have no employment at all. People living in public housing account for the majority of patients who visit the community health center. Without any other health care option, they must rely on the health center for all their medical needs. The lack of proper care is discouraging, but since they have no alternative, they must contend with what is currently available.

The level of education in the community is limited. Schools are not well maintained, gang violence is common, and drugs are sold openly. School dropout rates far outnumber the rates of those who complete their studies, leaving the population less educated and vulnerable to discrimination. Since the area comprises mostly of Black Americans, there are unique economic barriers facing the community. Development is minimal, making it difficult for young people to cultivate ambitions, which perpetuates social injustices and a lack of proper health facilities. Reduced income has caused many residents to avoid seeking medical help—even from the health center—for fear of being charged for care. The nurses who work at the community health center are mostly from other neighborhoods and do not closely understand the community's social dynamics.

Current Operations of the Community Health Center

The community health center is charged with providing outpatient medical services and care to area residents. Services include counseling, primary care, prenatal and postnatal care, and health education. The health center is supposed to offer services regardless of a patient's ability to pay, with care tailored to meet community needs. Studies have indicated that community health centers improve the health outcomes of their patients. However, in this case, that potential has not been fully realized. A majority of patients have complained that while they do gain access to primary care, receiving adequate information and thorough follow-through is quite difficult.

A key problem is that a patient is unlikely to meet the same nurse or doctor who handled their case previously. Patient handoffs are not conducted properly, so each patient must re-introduce themselves and restate their issue to every new medical personnel they encounter. Follow-up of patients is further complicated by the assumption among health care workers that someone else is responsible for it (Overbeck, Kousgaard, & Davidsen, 2018). This creates confusion in the operations of the health center, and patients end up suffering as a result.

Chronically ill patients are sometimes unable to make their appointments because they cannot leave their homes or lack someone to escort them to the facility. The health center is expected to maintain records of all chronically ill patients with regular appointments and to verify that those patients attend. In practice, however, health care workers appear overwhelmed, which can be attributed to a lack of proper communication and role definition.

A patient can wait at the health center for hours before being attended to, and any inquiry is typically met with the response to wait their turn. Some workers do recognize patients who have been waiting a long time and attempt to help them, but this is not always possible given shift changes and workload. When patients arrive at the facility, they are registered and called based on that register. Most of the time this system works adequately; the problem arises when files are misplaced or forwarded to the wrong office, causing patients to be called out of order.

Without appropriate care being offered, health workers risk violating their ethical duty of non-maleficence. They are obligated to ensure that no harm comes to their patients in the course of providing services. Poor communication increases the likelihood of prescribing incorrect medications or treatment: one provider might administer a medication to a patient, and a second provider, unaware of this, might administer another dose of the same medication—resulting in double dosing and potential adverse effects.

Proposed Collaborative Care Model

The proposed collaborative model will comprise teams made up of multiple caregivers, with the aim of ensuring integration of care within the health center. Primary care providers, care managers, and consultants will work together to deliver care and monitor patient progress. By ensuring collaboration among caregivers, communication will improve and patients will benefit from more comprehensive care. Having a multidisciplinary group of professionals discuss and develop treatment plans ensures that each individual patient receives appropriate consideration.

The model is designed to promote coordination and discussion among primary caregivers. For instance, in cases of mental health conditions, the team will comprise a social worker, a psychiatric nurse practitioner, a therapist, and a psychologist. With such a team in place, there will be internal accountability, checks and balances, and structured patient follow-up. This approach also helps protect team members from burnout when they face challenging scenarios, since no single member bears sole responsibility for a patient. Team discussions allow for collaborative delivery of care, and each member will have appropriate information on the progress of each patient.

References

LaBelle, C. T., Han, S. C., Bergeron, A., & Samet, J. H. (2016). Office-based opioid treatment with buprenorphine (OBOT-B): Statewide implementation of the Massachusetts collaborative care model in community health centers. Journal of Substance Abuse Treatment, 60, 6–13.

Overbeck, G., Kousgaard, M. B., & Davidsen, A. S. (2018). The work and challenges of care managers in the implementation of collaborative care: A qualitative study. Journal of Psychiatric and Mental Health Nursing, 25(3), 167–175.

Sanchez, K. (2017). Collaborative care in real-world settings: Barriers and opportunities for sustainability. Patient Preference and Adherence, 11, 71.

Smith, S. N., Almirall, D., Prenovost, K., Liebrecht, C., Kyle, J., Eisenberg, D., . . . Kilbourne, A. M. (2019). Change in patient outcomes after augmenting a low-level implementation strategy in community practices that are slow to adopt a collaborative chronic care model: A cluster randomized implementation trial. Medical Care.

Unützer, J., Harbin, H., Schoenbaum, M., & Druss, B. (2013). The collaborative care model: An approach for integrating physical and mental health care in Medicaid health homes. Health Home Information Resource Center, 1–13.