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Conference Proceeding

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Introduction - Vulnerable populations, including low-income individuals, minorities, homeless individuals, and migrant families have difficulty accessing primary care.1 Challenges include lack of funds, health literacy, transportation barriers, and language/cultural differences. Many have unmanaged chronic disease and poor health. The relationship between chronic illness and mental health issues is well established.2 Addressing these issues, a nurse-run center providing an integrated model of delivery (IMD) was created. Methods PrimeCare provides healthcare for the un/underinsured individual in western New York. The center is nurse-run, providing an IMD with a family nurse practitioner (FNP) and a licensed mental health counselor (LMHC). Individuals are screened for mental health issues using the DSM-V Self-Rated Level 1 Cross-Cutting Symptom Measure, screening across 13 domains. Possible links are identified between physical illness/chronic conditions and psycho-social stressors. Patients are then referred for counseling. Bi-weekly meetings between the FNP and LMHC focus on optimizing patient outcomes, facilitating collaboration between the disciplines. Results Since opening in 2013, there have been 1369 patient appointments, for an average patient census of 170. Patient outcomes were monitored to determine if the IMD had a positive impact on their health. Four major chronic conditions were addressed, including Diabetes, Hypertension, Hyperlipidemia, and Obesity. Patient data was reviewed to determine if their health outcomes improved, comparing patients that participated in counseling with those that elected not to participate. Initial findings demonstrated a positive outcome, though final data analysis is pending.


Presented at International Nursing & Midwifery Conference in Dublin, Ireland in March 2016.

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