Engaging Complex Patients With Drop-In Group Medical Appointments

Abstract

Traditional primary care is not designed to engage and support patients with complex social, behavioral health, and medical needs. Our Bridges to Health program offers drop-in group medical appointments (DIGMAs) that include a physician, a nurse care manager, a behavioral health counselor, peer support, a consulting occupational therapist, and a clinical pharmacist to provide a safe, accessible environment for such patients. Other services include care management; medication assistance; and transportation, nutrition, and social support.Over 6 years we have enrolled more than 500 patients, reduced their hospital utilization about 50%, and improved functional scores in over 2/3 of them. Once stabilized, most are able to transition to traditional primary care. WHO AND WHERE

In This Issue: Innovations in Primary Care and at the Annals

“…[1][2][3][4][5][6][7] Articles in this new feature are brief-they fit on a single page, with additional detail in online appendixes and other links. Each article describes an innovation from the front lines of primary care, how it works, who implemented it and where it was carried out-information readers need to make decisions about how to transport or reinvent the innovation in their own setting.…”