Using outreach enabling services to support the goals of a patient centered medical home
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Using Outreach & Enabling Services to Support the Goals of a Patient-Centered Medical Home. Oscar C. Gomez, CEO Health Outreach Partners Health Resources Services Administration Office of Rural Health Policy All-Grantees Meeting August 3, 2010* Washington, DC. Presentation Agenda.

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Using Outreach & Enabling Services to Support the Goals of a Patient-Centered Medical Home

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Using Outreach & Enabling Services to Support the Goals of a Patient-Centered Medical Home

Oscar C. Gomez, CEO

Health Outreach Partners

Health Resources Services Administration

Office of Rural Health Policy

All-Grantees Meeting

August 3, 2010* Washington, DC

Presentation Agenda

  • Introductions/About Health Outreach Partners (HOP)

  • Overview of the Patient-Centered Medical Home

  • About Outreach and Enabling Services

  • Farmworker Outreach Program Guidelines

  • Integrating Enabling Services

  • Q & A

Health Outreach Partners (HOP)

  • Since 1970, Health Outreach Partners (HOP) has been at the forefront of elevating the importance of outreach, recognizing the critical role it plays in facilitating primary care, case management, health prevention and social services to underserved, vulnerable and/or marginalized populations.

Health Outreach Partners (HOP)

  • Mission

    • Health Outreach Partners’ mission is to build strong, effective, and sustainable grassroots health models by partnering with local community-based organizations across the country in order to improve the quality of life of low-income, vulnerable, and underserved populations.

  • Priority Areas

    • Health Outreach and Enabling Services

    • Program Planning and Development

    • Needs Assessment and Evaluation Data

    • Health Education and Promotion

    • Community Collaboration and Coalition Building

    • Cultural Competency

Learning Objectives

  • Obtain a basic understanding of the Patient-Centered Medical Home (PCMH) with an emphasis on three key components: 1) medical team approach, 2) treating the whole person/patient, and 3) full coordination of care

  • Understand how outreach/enabling services staff functions as cultural brokers, learning and relaying key cultural information to medical teams about target populations served

  • Explore the role of outreach/enabling services in care coordination, especially as it relates to community health promotion via case management and health/wellness educational services

  • Learn best practices to improve access to care by understanding basic principles of integrating enabling services into health delivery systems to achieve a true “team-based” approach to care

Overview of Medical Home

What are Outreach and Enabling Services?

Outreach brings primary care services to underserved and/or marginalized community members to where the live, work, and congregate. Outreach improves patient follow-up, long-term case-management, and reduces health needs. Outreach activities may include, clinical assessments, patient follow-up and referrals, health education, patient navigation and advocacy, and organizing community events such as health fairs. HOP’s Outreach Reference Manual, 2007

Enabling Services are non-clinical services that are provided to primary care patients that promote, support and assist in the delivery of health care and facilitate access to quality patient care.

Joint Principles of a Patient-Centered Medical Home

Personal physician

Physician directed medical practice

Whole person orientation

Care is coordinated and integrated

Quality and safety (includes patient and family participation)

Enhanced access


The AAP, AAFP, ACP, and AOA, representing approximately 333,000 physicians developed these joint principles and issued them Feb. 2007

Outreach/Enabling Services and Patient-Centered Medical Homes

Eligibility assistance and financial counseling


Health education

Case management




Access and communication

Patient tracking and registry functions

Care management

Patient self-management support

Electronic prescribing

Testing and tracking

Referral tracking

Performance reporting and improvement

Advanced electronic communications


How do Outreach/Enabling Services Support Patient Centered-Medical Homes?

Outreach/Enabling services staff are part of the TEAM!

Outreach/Enabling services focus on the whole-person approach

Defines health broadly

Managing acute and chronic care


Integrating behavioral services into primary care.

Effective outreach/enabling services require the coordination and integration of care

Outreach/Enabling services understand the context of family and community

Recommendations for Supplemental Patient –Centered Medical Home standards for Medically Underserved Populations

Cultural proficiency

Enabling services

Community involvement

Workforce development

HOP’s Outreach Program Guidelines

The Outreach Program will:

  • 1) Serve as a liaison between the migrant/seasonal farmworker (MSFW) population and health/social service delivery systems.

  • 2) Share health information and provide health education services that are based on teaching methods which have demonstrated effectiveness with the MSFW population. This includes consideration for ethnic and MSFW cultural, educational, linguistic, and literacy factors.

  • 3) Take the lead in coordinating primary health care for the MSFW population and facilitate access to social services as necessary.

HOP’s Outreach Program Guidelines

  • 4) Advocate on behalf of the individual and the target population

  • 5) Include a clinical component to meet the basic health care needs of the MSFW population.

  • 6) Develop community networking and collaboration through outreach efforts.

  • 7) Take the lead in coordinating basic counseling and mental health support for the MSFW population.

Integrating Enabling Services to Support a Patient-Centered Medical Home

  • Outreach/enabling services aligned with other functions/departments and the community

  • Consistently coordinates, collaborates, exchanges information

Integrating Enabling Services to Support a Patient-Centered Medical Home

The Whole Person

The Team

Coordination and Integration of Care

Integration Strategies

  • Collect and share data on outreach and enabling services

  • Create outreach and enabling services protocols, clear job descriptions

  • Develop an integrated work plan

  • Increase cross-departmental communication

  • Build awareness about outreach and enabling services priorities

  • Involve clinical staff in outreach and enabling services activities

  • Involve outreach/enabling staff in clinical activities

  • Cultural sensitivity training

Tools for Integrating Case Management and Educational Services

  • UDS Reports

  • Referral Forms

  • Health education assessment forms

  • Case Management encounter forms

  • Organizational calendar, newsletter, and website

  • Staff meeting minutes

  • Departmental meeting minutes

For more information contact us…

Health Outreach Partners

405 14th St. Ste. 809

Oakland, CA 94612

(510) 268-0091

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