Medical Home Network's new model of coordinated care achieves ground-breaking results at Esperanza Health Centers

Care coordination technology and real-time alerts boost follow-up care by 130.4 percent

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Dec 11, 2014, 02:00 ET

CHICAGO, Dec. 11, 2014 /PRNewswire/ -- Medical Home Network announced today the results of a data review of its model of care program for Illinois Medicaid patients as implemented at Esperanza Health Centers' three primary care practice sites in Chicago's Little Village neighborhood on the southwest side, which shows as high as a 130.4 percent increase in timely patient follow-up visits, 25 percent decrease in 30-day hospital readmissions, and a decrease in the overall cost of care for each patient since the introduction of the new care model in December of 2012.

According to the review, Illinois Medicaid patients who were a part of Medical Home Network's program and visited their assigned primary care physician at Esperanza Health Centers within seven days after being discharged from the hospital or Emergency Department, increased from a 25.3 percent pre-implementation baseline to as high as 58.3 percent in certain months, with Esperanza's first intervention year averaging a 47.2 percent follow-up rate. The monthly-high of 58.3 percent represents a 130.4 percent increase over the pre-implementation baseline. In addition, hospital readmissions within 30 days of patient discharge decreased from 11.2 percent to 8.4 percent post-intervention, a 25 percent reduction in readmissions.

"We set an ambitious goal of reaching a 29 percent follow-up rate and in some months they have achieved more than 58.3 percent, more than double our goal," said Cheryl Lulias, president and executive director of Medical Home Network. "These are incredible, ground-breaking results by the team at Esperanza. They adopted the new model of care and exhibited the flexibility to transform their practice, which is what produced those results."

The Medical Home Network target for follow-up care with a primary care physician after hospital discharge is 29 percent. Traditionally, getting patients in for timely follow-up care is a challenge due to difficulties in coordinating care between hospitals and patients' primary care doctors. Each of the founding Medical Home Network partners at the six hospital systems and their physician practices plus the six Federally Qualified Health Centers (totaling more than 12 hospital sites and 120 primary care practice sites in Chicago and suburban Cook County), are collaborating to achieve that goal and to transform care coordination. Esperanza Health Centers, one of the founding partners of Medical Home Network, identified the key factors to not only achieving that goal, but surpassing it.

"Working with Medical Home Network, we have seen first-hand the impact that a coordinated and dedicated care team, at the practice level, can have on improving patient care," said Alejandro Clavier, MD, MPH, medical director of Esperanza Health Centers who shares his experience with the other partners of Medical Home Network at monthly meetings. "We each have a voice in this process. As Esperanza continues to share our successful strategies and experiences, I am optimistic that each of the medical centers in the Medical Home Network will share in the same level of success. We are all in it together."

In December of 2012, Esperanza worked with Medical Home Network to implement a new Model of Care, and a new care-coordination platform into the clinic. This system, MHNConnect, is a sophisticated, web-based care coordination portal which provides real-time alerts to primary care providers whenever patients utilize inpatient or emergency hospital services across the Medical Home Network community. Acting as a true Care Coordination Exchange, MHNConnect provides care coordinators with actionable, real-time alerts along with valuable historical data to assist providers and their care teams by giving them a holistic understanding of patients' health care utilization and needs. At the beginning, Carmen Vergara, the quality improvement nurse at Esperanza, adopted use of the portal into her everyday work schedule to start the process. After six months, the Esperanza team could see the great value of the Medical Home Network system, but realized it would require a full-time professional to coordinate care among providers and patients.

"From the data we could see that Esperanza's baseline follow-up rate was at 25.3 percent, while our rate during the first month in which we used the portal was 36.1 percent," said Vergara, whose duties include managing the care coordinators, which led her to hire veteran health professional Asenet Vallejo as a full-time care coordinator. "We knew we could do even better. We worked together on operational strategies to maximize the Medical Home Network model of care, especially the MHNConnect system, which acts as a true Care Coordination Exchange. Our goal was to increase patient follow-up appointments to the clinic. One of the key strategies was creating a policy which made patients discharged from the hospital a top priority for scheduling follow-up appointments. By working together, in our first year we were able to achieve an average timely follow up rate of 47.2 percent with rates as high as 58.3 percent in some months."

Given the influx of data and ability to identify discharged hospital patients in need of appointments with their primary care physician at Esperanza, the care team needed to find schedule opportunities to book those appointments. As a standard procedure, many clinics keep a block of time open each day to schedule appointments for patients with urgent health care needs. The executive team at Esperanza made the decision to start including discharged hospital patients into those blocks in order to meet the seven-day post-hospital scheduling goal.

"We find that if we call them within a day or two of being discharged, we can schedule them in by day three or four," said Vergara. "If they miss that visit, we still have a few more days to get them in for a timely follow-up appointment. The only way that's possible is if you can offer them a same-day appointment. Otherwise, they may have to wait two or three weeks, which is not the preference. Sooner rather than later is the goal."

Vergara says the key to Esperanza's success has been the connectivity of MHNConnect anchored by a trained workforce of care coordinators like Vallejo. The best example is Vallejo's vigilant work to contact patients by making repeated calls and sometimes even meeting them at the hospital, and then working with the Esperanza front desk professionals to find opportunities to schedule the patients.

"Those are the biggest factors for moving the percentage rate up to as high as 58.3 percent," said Vergara. "Anytime Asenet gets the alert on the portal, she knows she needs to contact them that day, and she does. Then, we all work together here to find options to get those patients in for their appointments, and that's what it takes – a total team effort."

Esperanza utilizes the MHNConnect portal to manage more than 3,000 patients. Vallejo says the patients really appreciate getting the call and often express their gratitude.

"From the patients perspective, getting a call from the physicians' office tells them that someone is on top of their care," said Vallejo, who will often make the trek across the street to St. Anthony's Hospital when she receives an alert on MHNConnect that one of the Esperanza patients is there. "That's when they realize that their doctor knows they were in the hospital and is reaching out to help them. I think that makes all the difference in the world for them. They know someone cares."

About Esperanza Health Centers

Esperanza Health Centers are dedicated to providing high-quality medical care to all residents of our southwest side of Chicago, regardless of immigration status, race, ethnicity, income level or insurance status. Families in Esperanza's service area experience significant economic, educational, and health disparities. All providers and clinical staff are bilingual and bicultural. More information is available at www.esperanzachicago.org.

About Medical Home Network

Medical Home Network is a Chicago-based health care collaborative devoted to transforming health care delivery for Chicago Medicaid patients by fostering collaboration and innovation among safety net providers. Health care providers, like Esperanza, work directly with Medical Home Network to implement a new model of care, which is anchored by care coordinators who combine the efforts of institutions and leverage unprecedented virtual connectivity and technology to benefit the overall health care for almost 200,000 Chicago-area Medicaid patients. More information is available at www.MHNChicago.org.

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SOURCE Medical Home Network