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Complex Patient Centered Medical Home

Some patients need more support. We created a model to provide it.

For some patients, needs in the social determinants of health – housing, food, transportation, etc. – are just as critical as their medical issues. These non-medical social determinants of health impact medical outcomes and costs immensely. These needs make the care of these patients complex, requiring the coordination of medical and social services.

In the Complex Patient Centered Medical Home model, the provider takes responsibility for this coordination of care across the community in addition to the primary medical care.

Community First worked with Hilo Medical Center and HMSA to create a Complex Patient Centered Medical Home model based on a personal relationship between the patient and a community health worker. Initial clinical and financial results have been promising, and we are working with Bay Clinic and the East Hawaiʻi IPA to develop similar models.

Related: Community Action Network

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