Northwestern Follow up Clinic: Connecting Patients to Better Health and a Permanent Medical Home

Project: Research project

Project Details


Project hypothesis: We predict that by providing a group learning opportunity that
focuses on health care self-advocacy along with rapid access to outpatient care upon
discharge, we can better address patients’ acute and chronic medical needs , help patients
overcome barriers to care and connect them to a medical home which will improve their
long term health outcomes.
Project scope: The initial NFC clinical visit will include a detailed medical assessment by
a physician as well and a psychosocial assessment completed by a medical social worker
to identify health care needs and barriers to care. An individualized care plan for the
patient will then be developed after these comprehensive assessments. The NFC
provides short-term medication support as needed and develops a financially sustainable
long-term treatment plan. In the Women’s Wellness Group component, we will be using
psychoeducation and drawing on cognitive behavioral techniques and other treatment
modalities as we explore self care and stress reduction, how to build healthier
relationships, get the most out of health care visits, and life skills including budgeting.
Participants will meet weekly for four weeks with the opportunity for group renewal.
Once medically and socially stabilized we will connect the patient with a permanent
medical home in their community.
Specific goals and objectives:
1) Improve long term health outcomes by providing patient-centered care, empowering
patients, and educating them about the importance of health maintenance and prevention.
2) Empower patients to better manage their health by addressing complex barriers to care
including medication access, transportation and improving food stability.
3) Additional women’s resources will be offered via a group intervention to determine its
impact on patient care utilization.
4) Once patients have been medically stabilized, we will connect them to providers in their
community for ongoing long term care and a permanent medical home.
Effective start/end date9/1/138/31/14


  • Northwestern Memorial Hospital (Exhibit B.4)


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