The Complex Patient Centered Medical Home is a center of excellence in the care of patients for whom the social determinants of health (SDOH), such as housing, food, and transportation, are as critical as medical issues. These non-medical social determinants of health impact medical outcomes and costs immensely. They make the care of these patients’ complex, requiring the coordination of medical and social services. In addition to providing primary care, the C-PCMH takes responsibility for this coordination of care across the community.
CF worked with Hilo Medical Center (HMC) and Hawaii Medical Service Association (HMSA) to create a C-PCMH Model based on a personal relationship between the patient and a community health worker. Initial clinical and financial results have been promising and we are working with Bay Clinic and the East Hawaii IPA to develop similar models.