With a large proportion of high-risk patients who suffer from a disproportionate array of chronic conditions, Community Health Centers must take innovative steps to manage care and offer preventive services. As seen during the COVID-19 pandemic, this can be done in the safety of patients’ homes. Individuals who suffer from chronic health conditions are also more likely to experience severe illness if infected with COVID-19, so providing patients with tools to receive primary care while at-home can help reduce their risk of complications.
More opportunities to receive primary care at home now, and into the future, also helps ensure patients receive the right care, at the right time, and in the right place. A “Patient Care Kit” is the name the NACHC team has given to a toolbox of patient self-care tools, supplies, education, and instruction. Used as part of virtual care, these Kits are a groundbreaking strategy to advance a health center’s virtual patient care process.
Kits can be designed to include items targeting common, high-cost, high-prevalence conditions such as: diabetes, hypertension, obesity, and colorectal cancer. Using NACHC’s Value Transformation Framework, this guide presents a systems-approach to transform patient care through the use of Patient Care Kits as part of virtual care. This transformational approach allows health centers to simultaneously focus on improving health outcomes, improving patient and staff experience, reducing costs, and advancing health equity (the Quintuple Aim).
This guide draws on the experience of 20 health centers across the country participating in NACHC’s Leading Change: Transforming At-Home Care pilot project. This project provided health centers with Patient Care Kits that have been placed in the hands of nearly 400 patients as an innovative approach to advancing virtual care. While the pilot project is still in progress, NACHC offers this guide as a framework for health centers to design at-home patient care strategies based on the models, lessons, and experiences learned to-date.