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My Health GPS |
District of Columbia |
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My Health GPS is a care coordination program that uses interdisciplinary care teams embedded in primary care settings to address complex patients' medical, behavioral and social needs. Specifically, the program aims to improve health outcomes and reduce avoidable hospitalization/ER visits by helping complex patients coordinate care; manage their conditions through medication, diet and exercise; and access services to meet unmet social needs like housing, transportation and education. |
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Partner Organizations |
D.C. Department of Health Care Finance, various healthcare and social service providers |
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Target Population |
Medicaid beneficiaries with three or more chronic conditions |
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Care Team |
Varies by acuity level, but generally includes: health home director, nurse care manager, peer navigator/community health worker, care coordinator/social worker and clinical pharmacist |
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Timeframe |
2017 - present |
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Results/ Studies |
The effectiveness of the progam will be measued based on its ability to: lower the rate of avoidable ER use; reduce preventable hospital admissions; lower hospital readmissions. Evaluations are forthcoming. |
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Funding |
Medicaid |
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Resources |
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