Advancing Innovation: the Community-Based Health Home
ALE designed and successfully tested the Community Based Health Home (CBHH), the first model in the nation to advance the Triple Aim by allying national health home standards with the multi‐faceted Adult Day Health Care (ADHC)/Community Based Adult Services (CBAS) team‐based service platform.
In partnership with the primary physician, the CBHH model comprehensively strengthens effective care and support for vulnerable, chronically ill adults by intensifying ADHC’s “high touch” nursing care coordination and in‐depth assessment of needs, as well as the addition of transitional care support, patient activation, and education to advance health literacy. The result is the creation of a uniquely effective person‐centered health home to support choice, independence and dignity through community living for adults at high risk of institutional placement. With an exceptional track record to date, the CBHH model was the catalyst for centers in the Bay Area and Los Angeles County to become designated as health home contractors through their managed care plans. Peer-Reviewed Evaluation of CBHH
Dr. Sadarangani, Assistant Professor/Faculty Fellow in the NYU Rory Meyers College of Nursing, has conducted a mixed-methods evaluation of the Community Based Health Home (CBHH) Project published in 2019. This evaluation entailed a quantitative analysis of participants' descriptive data; clinical assessments over time; and health care utilization. Dr. Sadarangani also executed a qualitative research component assessing the experiences of older adults, their caregivers, and their healthcare providers – all of whom participated in the CBHH project. Project Goals The purpose of this evaluation was to examine outcomes and document the experiences of individuals who participated in the Community Based Health Home Project and isolate components that were highly effective and contributed significantly to positive health outcomes. This also serves to highlight any inefficiencies in this model which will contribute to targeted improvements. Results: Outcome data was gathered using standardized evidence‐based tools consistent with national standards and which address cultural diversity, measure quality of life for participants and caregivers, and are effective with participants who have cognitive disabilities. TOPS™ (Tracking Outcomes for Program Success), a web‐based data and benchmarking system developed for adult day services, was used to aggregate this data and create reports to communicate with physicians and track participant well‐being over time. These assessment tools are available in eight languages, reflecting the diversity of the CBHH population. |
Dr. Sadarangani is an Assistant Professor at New York University Rory Myers College of Nursing who has studied the Community Based Health Home Project and published peer-reviewed articles with her findings. A board-certified adult/gerontological primary care nurse practitioner (NP) with experience in both primary care and specialty settings, Dr. Sadarangani’s research interest is exploring barriers to health access and community-based services for elderly immigrants. Her work has received significant funding from the National Hartford Centers for Gerontological Nursing Excellence and the Hillman Family Foundation. She was recognized as a Patricia G. Archbold Scholar by the National Hartford Centers for Gerontological Nursing Excellence from 2014-2016 and received $100,000 in funding. She was a Fellow of the Hartford Institute of Geriatric Nursing at NYU. In addition to her PhD from NYU, she holds an MS in Nursing from the University of Pennsylvania, a BS in Nursing from NYU, and a BA in Anthropology from Georgetown University. |
Original Community Based Health Home Pilot Sites (2012-13) gather for training in Sacramento
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CBHH participants and Nurse Navigators work together to stabilize health and improve wellness