Yale Internal Medicine Partners with Two Federally Qualified Health Centers in Innovative New Care Consortium

Last Monday, faculty members from the Yale Section of General Internal Medicine helped open the doors of the New Haven Primary Care Consortium, beginning an innovative journey of collaborative medicine with the goal of revolutionizing primary care in the New Haven area.

The NHPCC is located at 150 Sargent Drive in Long Wharf, New Haven and is a partnership of Yale New Haven Hospital, Cornell Scott-Hill Health Center, and Fair Haven Community Health Center that will have critical input and leadership from Yale School of Medicine faculty.

This collaboration is unusual, says Bradley Richards, MD, assistant professor of medicine (general medicine) and assistant medical director for the NHPCC’s Cornell Scott-Hill Health Center Adult Medicine Practice.

“It is unusual to have two Federally Qualified Health Centers (FQHCs) under the same roof,” says Richards, referring to the Cornell Scott-Hill and Fair Haven Community Health Centers. “That’s the unique nature of what we’re doing here, where there’s a lot of collaboration.”

Unusual though it may be, discussions of this collaboration have been happening on and off for at least 30 years, says Patrick O’Connor, MD, MPH, MACP, Dan Adams and Amanda Adams Professor of General Medicine and chief of General Internal Medicine.

“The idea has been out there but it didn’t gain traction until about three years ago,” says O’Connor.

Now that it has, the excitement across the department is palpable.

“This is a great opportunity for us to work closely with our colleagues in the community,” says O’Connor. “And undoubtedly it will be a two-way learning process. This unique partnership will combine the expertise of community and academic physicians and other health care professionals to the benefit of our patients and community more broadly.”

For Brita Roy, MD, MPH, MHS, assistant professor of medicine (general medicine) and director of Population Health for Yale Medicine, the excitement around this collaboration lies in the opportunity to improve population health.

“The hope is that with all of these clinics merged together serving the lower income population in New Haven, we’ll be able to really collaborate and coordinate to develop robust population health systems to better support our most vulnerable,” says Roy.

She names the expansive data and resources from the networks of these three care providers as key to co-designing programs to improve systems—and, therefore, health outcomes.

O’Connor agreed. “The opportunity for us to leverage this collaboration and think creatively about building highly innovative approaches to population health is very exciting.”

John Moriarty, MD, FACP, associate professor of medicine (general medicine) and program director for the Primary Care Internal Medicine Residency Program, is particularly excited about what this new consortium will mean for his residents.

“Education in this environment will change,” says Moriarty. “One of the more effective ways to educate residents and students about primary care is to have a team-based approach to education, and understanding that high functioning primary care teams are made up of much more than the physician. There’s the pharmacist, the nurse, the medical assistant, etcetera. You need everyone working at the highest level to optimize care plans for patients. The NHPCC gives residents the opportunity to look at true inter-professional care at a high level.”

One new aspect of that inter-professional care at the NHPCC is an integrated behavioral health team. This team includes psychiatrists, psychologists, and licensed clinical social workers who will now work side by side.

“In the past we’ve struggled to get patients the behavioral mental health care they need when they needed it,” says Daniel Tobin, MD, FACP, associate professor and medical director of Primary Care alongside Laura Whitman, assistant professor of medicine (general medicine). “So having access to an integrated behavioral health team is a significant enhancement. They’re right next door, so if we have a patient who needs to see someone for an urgent behavioral health issue, we can send them right over.”

And, says Moriarty, that integrated behavioral health will teach residents how to effectively care for patients, thereby improving the next generation of physicians in primary care.

So far, the response from patients has been a positive one.

“I have seen quite a few patients in the new space already,” says Tobin. “I think everyone’s really excited, the space is beautiful, the physical plant is just a significant upgrade from what we’re used to, so everyone’s impressed.”

Looking forward, O’Connor is focused on creating a seamless patient transition from outpatient, inpatient, and community health care.

“The transmittal of information in large medical centers like ours can be fragmented at times,” says O’Connor.

“We want to build comprehensive teams who will assure that patients transition between the clinic, and the hospital, and the community with the goal of achieving high quality and cost effective care for the benefit of all patients and their families.”

O’Connor says he and his team are already beginning to design a more robust approach to seamless care as they simultaneously settle into the new NHPCC space and explore how this collaboration will elevate the collective care the consortium is able to provide to the New Haven community.