What innovations drive success in population health? Here's a tactic from a high performer on the athenahealth network.
Serving the Midwest's largest population of recent immigrants from Latin America, Esperanza Health Centers, a federally qualified health center in Chicago, cares for 72,000 patients each year, 63 percent of whom are covered by Medicaid, 21 percent of whom are uninsured, and too many of whom turn to the emergency departments of local hospitals for primary care.
To reduce unnecessary utilization — and avoid overloading their staff — Esperanza needed to know more context to assess the urgency of the visit and coordinate follow-up care.
Now, the moment an Esperanza patient registers in the emergency department of one of 22 hospitals in the city, the feed pings Esperanza care coordinators. MHNConnect puts the alert in the context of each patient's assessed health risk based on claims and other data. And depending on risk level, the coordinator either immediately heads over to the ED to meet the patient or calls to arrange a follow-up appointment within seven days.
Combining ADT feed with weekly claims data, says Art Jones, M.D., and chief medical officer of Medical Home Network, enables coordinators to tailor their next steps to each patient.
They can follow up education about ER use at the next visit, he says, or “They can prioritize, saying, 'This is somebody for whom I don't have a phone number. I don't have an address. They keep going to the emergency room for primary care. I'm going to leave my practice and go and engage with that person in the emergency room.'"
That more intensive outreach has led to concrete results. The MHNConnect technology and follow-up care coordination have reduced the total cost of care of Esperanza's patients by 3.5 percent in single year and by 5 percent over two years. "This is a tool," says Jones, “that is really essential to effective care management."
Brenna Mayer is a Boston-based freelance writer.