4 Ways to Help Vulnerable Patients Engage with Primary Care

1. Bring primary care to patients

Health and healthcare today extend far beyond provider offices and traditional healthcare settings. Many critical determinants of health occur outside the exam room, such as sleep, diet, exercise, stress, and substance use. These factors significantly impact our well-being at home, work, and in daily life.

Primary care often relies on patients and families to take the initiative — making appointments, getting screened, and reporting symptoms. While this approach works for many, it frequently falls short in disinvested communities and among diverse populations, including Medicaid recipients and those facing SDoH barriers and complex chronic conditions. In these communities, providers must be proactive and take the initiative to bring primary care to the patients.

This outreach can take various forms, such as offering free clinical exams and preventive screenings at community festivals or deploying a mammogram van to engage patients directly in their neighborhoods. It can also involve community-based teams — including nurse practitioners, community health workers, social workers, and members of the clergy — visiting patients in their homes and other community sites. These teams can assess the needs of patients, caregivers, and families; provide education and spiritual support; connect with community-based organizations; help patients re-engage with their PCPs; and ensure they receive appropriate care and human services.

2. Use technology 

The average Medicaid-focused PCP operates on a narrow margin and a busy schedule. Medicaid reimbursement requires providers to see 24 or more patients a day just to break even. This demanding pace leaves little time for important administrative tasks, such as recording comprehensive notes, filing claims and appeals, reporting on quality metrics, scheduling, and patient outreach and education. PCPs serving vulnerable populations often need to perform more outreach than their counterparts in better-resourced communities, but they typically lack the resources to do so. This additional burden strains already overtaxed staff and jeopardizes the financial stability of the practice.

Action-oriented practice management technology that leverages data from health information exchanges (HIEs), electronic health records (EHRs), and other sources, along with predictive analytics, can help providers identify patients in need of care and services. This technology can trigger practice staff to proactively reach out to these patients via phone calls or text messages. Additionally, technology can automate administrative tasks, assist providers in managing patient care at both individual and population levels, and help meet VBC performance and reporting requirements.     

3. Provide culturally attuned care

To be truly effective, primary care should be attuned not only to individual patients, but to the racial, ethnic, religious and socioeconomic communities to which they belong. This can range from providing interpreters for non-English speakers and educational materials in multiple languages to addressing cultural norms that influence patients’ approach to healthcare.

Providers need screening tools to identify and address issues affecting patients’ ability and willingness to access care, such as trauma, mental health concerns, or cultural values. These factors are crucial for sustaining therapeutic relationships and promoting person-centered outcomes. Practices must ensure their outreach efforts and programs are culturally relevant and that clinicians and staff are trained to provide care with cultural humility. 

4. Partner with a VBC enabler and work with community allies

PCPs don’t have to go it alone in their mission to bring primary care to vulnerable patients. Practices can align themselves with non-profit groups, religious organizations and VBC enablement partners to address the range of patient issues.  VBC “enablers” provide the technology, tools, risk-based financial support, activity-based payments, practice management consulting, cultural humility training, and community-based clinical supports to help these practices be successful in VBC.