The team also Identified perceived housing and education barriers in a patient that was starting college soon. The patient’s current housing did not enable them to attend school, so new housing was found that would allow them to continue treatment and attend college. The patient also expressed that they were not able to afford a laptop for classes. The care coordinator was able to connect the patient with a source from which they can borrow a laptop for the semester.

The Tri-County Family Medicine and Casa Trinity team identified perceived transportation barriers in patients who couldn’t make appointments because they had to rely on others. The team identified that the patient needed help with registration fees to put a vehicle on the road. The fee was within the parameters of the pilot’s incentive program and the care coordinator accompanied the patient to the DMV to get the car on the road.

FLIPA set out to identify gaps in care for patients included in the pilot program and generate performance reports. Those patients hadn’t seen their PCP in more than a year.

Using the data, we coordinated care across all health centers and behavioral health providers, connecting care managers who would arrange for providers to call patients, make house visits, or have them come into the office.

FLIPA organized monthly meetings to review results, share best practices, and brainstorm new approaches among participating providers.

As a result, we closed the gap and increased access to care across the patients included in the pilot, pulling them back into the continuum of care after a long absence. The resounding success of our efforts led us to secure our own software platform, Bridge, to expand the best practices learned from the JOG program.