Gateway to Health: An Innovative Model for Primary Care Expansion in Detroit

The award will enable the Detroit Medical Center (DMC) to test an innovative primary care and preventative health model that reaches patients who use some of Detroit’s busiest emergency departments. 

The project will make patient-centered medical care immediately accessible to individuals without existing primary care physicians, arriving to four DMC emergency departments at DMC Harper University Hospital, DMC Detroit Receiving Hospital, DMC Sinai-Grace Hospital and DMC Children’s Hospital of Michigan. By embedding primary care services in those areas of highest emergency department use, the DMC project intends to meet patients where they are already seeking care to develop meaningful doctor-patient relationships, improve care coordination and implement strategies to promote wellness. The ultimate goals are to deliver improved health care access, quality and efficiency for the surrounding community. 

The focus will be on improving the care provided to patients with diabetes, asthma, hypertension, heart failure, chronic lung disease, depression and HIV.  Emergency department “super-utilizers” who have 10 or more visits annually are another program target group. Medicaid, Children’s Health Insurance Program (CHIP) and Medicare fee-for-service beneficiaries will be the dominant populations. 

A multidisciplinary team of caregivers will work closely with each patient to help them achieve wellness through prevention and self-management of their conditions. Face-to-face visits, telephone contact and texting will all be used to better connect patients to the care team. Patient coaches and navigators are essential to the model as well. 

The award amount is $9,966,608 over three years.