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

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.