Unity Health Care
Program Name: Patient Centered Medical Home Enhancement Grant
Grant Amount: $913,801/3 years
Unity has a network of 29 health centers and a mobile medical outreach vehicle, which are strategically located within all eight Washington, DC wards. Unity offers primary health care services to the homeless, working poor, under/uninsured, infants, school-age children, the elderly, persons living with HIV/AIDS and/or hepatitis, as well as those who are incarcerated and recently released from jail and prisons. Their scope of primary health care services includes: internal, pediatrics, family practice and obstetric/gynecological medicine. They also offer dental care, social services, mental health, family planning, treatment adherence, substance abuse counseling and numerous specialized services.
Unity began transformation to a PCMH in 2007. This program is designed to enhance the current patient centered medical home by increasing care coordination to support the most vulnerable patients. Specifically the grant will support development of an ER diversion team to provide intense outreach and patient engagement services, enhance care coordination practices, and increase accessibility to primary care services through urgent care alternatives. Teams will consist of staff members from nursing, social services, and registration, along with a community health worker. Team will be responsible for calling patients, providing outreach visits, visiting local ERs, and following up with patients. There will also be increased access through extended hours during the week and on weekends. The grant funding will support service personnel.