Skip to main content

Main menu

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers

User menu

  • My alerts

Search

  • Advanced search
Annals of Family Medicine
  • My alerts
Annals of Family Medicine

Advanced Search

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers
  • Follow annalsfm on Twitter
  • Visit annalsfm on Facebook
OtherInnovations in Primary Care

Interdisciplinary Group Visits for Patients With Complex Social Needs

M. Rebecca Hoffman, Meghan Golden, Janice Frueh, Nichole Mirocha and Tracey Smith
The Annals of Family Medicine January 2020, 18 (1) 83; DOI: https://doi.org/10.1370/afm.2467
M. Rebecca Hoffman
MD, MSPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: mhoffman51@siumed.edu
Meghan Golden
LCSW
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Janice Frueh
PharmD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Nichole Mirocha
DO
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Tracey Smith
DNP
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

THE INNOVATION

To make a positive impact on patients who struggled to achieve improved health outcomes in the primary care setting, we redesigned our Federally Qualified Health Center’s (FQHC) usual approach to outpatient services, developing a multidisciplinary team approach called the Comprehensive Care Clinic (CCC).

WHO & WHERE

The CCC was developed in the Southern Illinois University (SIU) Center for Family Medicine, an FQHC in Springfield, Illinois. Building on previous collaborative work with student hotspotting (Supplemental Appendix at http://www.AnnFamMed.org/content/18/1/83/suppl/DC1 and https://hotspotting.camden-health.org/), we developed an interprofessional team consisting of a family physician (MD/DO), pharmacist (PharmD), behavioral health provider (LCSW), public health nurse (DNP), community health workers (CHW), and psychiatrist (MD). Interprofessional learners and medical residents are also routinely involved.

HOW

Patients are recruited/engaged into the CCC through several pathways: community agencies (including the local police department, probation and treatment courts, and local shelters), patients who are already engaged in our student hotspotting program, and patients who are struggling with the usual clinic’s care processes.

A team huddle occurs before each clinic, during which plans are made for which team members will see each patient, based on that patient’s specific medical, psychiatric, and social needs. Several team members often see the patient during a CCC, and some may not need to see the patient at all; therefore, patients see different combinations of the nurse, physicians, pharmacist, resident or student learners, and behavioral health provider, often with the psychiatrist involved in case discussion without entering the room. Team members have received training in, and consistently utilize, patient-centered engagement techniques such as motivational interviewing, trauma informed care, accompaniment, and harm reduction. Approximately 10 patients are seen in each half-day clinic, with any team members who are not in the room during a patient encounter facilitating follow-up and delivery of services for patients as needed. There is an informal debriefing session following clinic.

We have been pleased to see that patients who had previously been labeled as “noncompliant” or “difficult” have successfully engaged in primary care services, and “no-show” occurrences are rare. Financial sustainability has been possible through traditional physician and mental health service reimbursement with both the physician and behavioral health providers billing separately, as well as CHW funding though grants; agreements with managed Medicaid for CHW services are now in place to maintain sustainability.

LEARNING

Replication of this model is possible in other primary care settings but requires careful selection of team members and a high level of enthusiasm. The team and clinical environment must be willing to “relax the rules” to help these patients succeed, and a non-judgmental attitude is paramount. Team members often cross the typical boundaries of their job descriptions, working in true interdisciplinary fashion. The CHWs’ role cannot be overemphasized, especially when it comes to continued patient engagement.

This team is unique in its composition and fluidity and has learned that it is essential to move beyond what are currently considered progressive and innovative models (such as traditional group visits, sequential provider visit models, and integrated behavioral health care) to meet the needs of patients with highest levels of complexity. We have found that it is not enough to have “on call” interdisciplinary team members; these individuals must all be present during visits and have in-depth conversations about patients together in order to close gaps in care and move quality of treatment to a higher level.

Footnotes

  • Conflicts of interest: authors report none.

  • For additional information, including supplemental materials, key words, author affiliations, and funding support, see it online at http://www.AnnFamMed.org/content/18/1/83/suppl/DC1/.

  • © 2020 Annals of Family Medicine, Inc.
PreviousNext
Back to top

In this issue

The Annals of Family Medicine: 18 (1)
The Annals of Family Medicine: 18 (1)
Vol. 18, Issue 1
January/February 2020
  • Table of Contents
  • Index by author
  • Back Matter (PDF)
  • Front Matter (PDF)
  • In Brief
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Annals of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Interdisciplinary Group Visits for Patients With Complex Social Needs
(Your Name) has sent you a message from Annals of Family Medicine
(Your Name) thought you would like to see the Annals of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
1 + 8 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
Interdisciplinary Group Visits for Patients With Complex Social Needs
M. Rebecca Hoffman, Meghan Golden, Janice Frueh, Nichole Mirocha, Tracey Smith
The Annals of Family Medicine Jan 2020, 18 (1) 83; DOI: 10.1370/afm.2467

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Get Permissions
Share
Interdisciplinary Group Visits for Patients With Complex Social Needs
M. Rebecca Hoffman, Meghan Golden, Janice Frueh, Nichole Mirocha, Tracey Smith
The Annals of Family Medicine Jan 2020, 18 (1) 83; DOI: 10.1370/afm.2467
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • THE INNOVATION
    • WHO & WHERE
    • HOW
    • LEARNING
    • Footnotes
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Reducing Stigma Through Conversations in Primary Care About Unhealthy Alcohol Use
  • Adult ADHD Diagnosis in a Family Medicine Clinic
  • Enhancing First Trimester Obstetrical Care: The Addition of Point-of-Care Ultrasound
Show more Innovations in Primary Care

Similar Articles

Subjects

  • Person groups:
    • Vulnerable populations
    • Community / population health
  • Methods:
    • Cross-disciplinary
  • Core values of primary care:
    • Coordination / integration of care
  • Other topics:
    • Organizational / practice change

Content

  • Current Issue
  • Past Issues
  • Early Access
  • Plain-Language Summaries
  • Multimedia
  • Podcast
  • Articles by Type
  • Articles by Subject
  • Supplements
  • Calls for Papers

Info for

  • Authors
  • Reviewers
  • Job Seekers
  • Media

Engage

  • E-mail Alerts
  • e-Letters (Comments)
  • RSS
  • Journal Club
  • Submit a Manuscript
  • Subscribe
  • Family Medicine Careers

About

  • About Us
  • Editorial Board & Staff
  • Sponsoring Organizations
  • Copyrights & Permissions
  • Contact Us
  • eLetter/Comments Policy

© 2025 Annals of Family Medicine