Connecting Group Care Patients to Mental Health and Food Resources During the COVID-19 Pandemic

INNOVATION

The COVID-19 pandemic has prevented in-person group medical visits. The underserved population at our federally qualified health center in Denver, Colorado was at heightened risk of food insecurity and mental health concerns. We adjusted the model to offer virtual group visits, schedule families for individual medical visits, and screen patients for food insecurity and behavioral health needs.

WHO & WHERE

We reached out to families, both Spanish- and English-speaking, who received group prenatal and/or well-child care at our clinic. The clinic serves a neighborhood that faces several disadvantages compared with other areas in the city, including food insecurity, a significant portion of uninsured individuals, low high school graduation rates, and high rates of childhood obesity and asthma.

HOW

The program goals, which draw from the Centering Pregnancy¹ model of prenatal care and the Bright Futures Guidelines,² are to foster healthy relationships, provide high-quality health care, and increase access to behavioral health support and early intervention for underserved families in a culturally responsive and relationship-based model of care. Pre-pandemic, cohorts of 10 to 12 pregnant women met in a group for 10 sessions facilitated by a bilingual, bicultural care coordinator and a bilingual licensed clinical psychologist while they received prenatal care from the group’s primary care physician. After delivery, the cohort continued in a group setting for all well visits with the same staff (care coordinator, medical assistant, psychologist, and medical provider) until children turned 4. Families who needed additional psychosocial support were offered individual visits.

During the COVID-19 pandemic, the care coordinator and psychologist have continued to regularly meet with families for virtual group sessions to offer social support and discuss curriculum topics. Instead of group medical visits, the care coordinator schedules families for individual preventative care visits and conducts standardized screening on food insecurity, mood, and child behavior concerns. Approximately 26.5% of patients identified food insecurity and approximately 18.3% identified mood or behavior concerns. The group care coordinator schedules patients who endorse behavioral health needs or mood concerns with the psychologist, whom patients already knew and trusted through the group care model. The group care coordinator refers families to the clinic social worker and offers to directly schedule these appointments to encourage referral completion.

LEARNING

Relationship-based, culturally congruent care has allowed our medical clinicians, group care coordinator, and psychologists to effectively pivot during this pandemic and offer support and resources to underserved families. Outreach from our bilingual and bicultural group care coordinator means that families had a trusted source from whom to receive support. Standardized screening with a clear workflow ensures the care coordinator has a triage process to manage concerns within her scope to prevent burnout. Given that the mental and physical health disparities stemming from the pandemic are likely to become even more evident in the future, service delivery systems must be ready to meet these needs. Primary care clinics can create workflows that support the formation and utilization of trusted relationships (eg, patient navigators, care coordinators, and behavioral health professionals) to reach vulnerable populations during and after the pandemic to promote collective recovery and resilience.