The Greater Roslindale Medical & Dental Center (GRMDC) serves patients from Boston and surrounding neighborhoods with many patients coming from the neighborhoods of Roslindale, West Roxbury, and Hyde Park. They have a diverse patient population providing primary and specialty care in Albanian, Greek, Portuguese and Spanish as well as English. GRMDC’s Complex Care Management (CCM) program provides care management and coordination to adults, pediatric patients and families, and mothers in the perinatal period who have complex medical needs.
ICH provided TA to help GRMDC understand the patient risk identification and engagement protocols being used, staff expectations and activities, and overall strengths and challenges of the program. ICH’s support included a literature review of patient identification and engagement strategies and a series of qualitative interviews with GRMDC staff to gather feedback about the CCM program from a variety of perspectives. ICH also provided assistance to help GRMDC define an electronic health record data set and provided analytical support to create a quantitative description of the CCM population. ICH synthesized findings and facilitated a discussion about how this information could be applied to make improvements to GRMDC’s CCM program in the future. As a next step, ICH will be providing TA to help GRMDC develop a logic model detailing program activities and outcomes that can be used as a foundation for a long-term evaluation plan. Overall, ICH’s TA has provided GRMDC with information and recommendations that they can use to refine their program structure, staffing, and patient identification and engagement processes.