HIE tracks the center’s cohort treated in other health facilities to ensure continuity of care and minimize duplicate resource use
THE ANGEL, March 24, 2021 / PRNewswire / – The Los Angeles Network for Enhanced Services (LANES) announced today, the Arroyo Vista Family Health Center, leverages its community health data from local hospitals, outpatient locations, and behavioral health centers. Arroyo Vista leverages Health Information Exchange (HIE) data insights concurrently with the LANES Population Health Improvement Tool to better track and manage the continuity of service delivery activities for the underserved population, especially the chronically homeless.
(PRNewsfoto / Los Angeles Network for Enhance)
Since October 2020Arroyo Vista has continuously monitored approximately 100 high-risk patients participating in the California Medi-Cal Health Homes Program (HHP). HHP serves eligible Medi-Cal beneficiaries with complex medical needs and chronic illnesses who can benefit from improved care management California Counties, Medi-Cal Managed Care Plans, and Healthcare Providers. These entities work together to coordinate services to avoid duplication.
“The homeless are by definition high-risk. They often have multiple chronic conditions and are difficult to reach because of their illness,” said Alex Cotté, MHA, director of managed care services. “By making this subpopulation available for tracking in LANES, our care coordinators can determine if any of their patients have checked into a nearby health facility.”
The nursing teams at Arroyo Vista’s five State Qualified Health Centers (FQHCs), including a mobile medical clinic, are across from each other Northeast Los Angeles Use LANES to access up-to-date hospital admissions, discharges, diagnostic results, and technical reports. The HIE marks patients who need early intervention and identifies high users of health resources. Overuse of health care resources, such as avoidable emergency room visits and readmission to hospitals, are a major contributor to waste in the US healthcare system.
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“To understand the direct correlation of social determinants of health with clinical outcomes, our ultimate goal in using LANES is to participate in the Health Homes program to improve internal resources, including the readiness of tools for better assessment our health needs in the population and to timely and appropriately link the patient reach, “said Cotté.
Impact of costly readmission and costs
LANES helps Arroyo Vista Nursing Coordinators keep track of their patient population, regardless of whether people are seen in the emergency room, admitted to or discharged from a LANES hospital participant.
Hospital readmission is associated with poor patient outcomes and high financial costs. In addition, the hospital-to-community transition with a 30-day readmission rate greater than 20 percent is fraught with risk for patients. Poorly coordinated care transitions result in unplanned readmission at an estimated cost of $ 20 billion yearly. General practitioners are challenged to coordinate patient care when, in many cases, they do not even know that their patients have been hospitalized.
“We use the encounters with the patient’s healthcare system recorded in LANES to get in touch with our managed care members and local providers and to ensure appropriate case management,” said Cotté. “We can inform that person’s care plan when problems arise in one or more healthcare facilities and are confirmed.”
Connect community providers
The expansion of the recommendations of community providers through Arroyo Vista due to the use of LANES has led to a positive result and at the same time coordinated the care of the under-served risk cohort Northeast Los Angeles.
“It was extremely helpful to be visible across the care locations where other clinicians interact with our HHP patients and are on the LANES network,” noted Cotté. “These providers also need shared patient data because they are fully involved in coordinating HHP care.”
According to Ali Modaressi, CEO of LANES: “At Arroyo Vista, LANES supports community health initiatives such as the Health Homes program, where patients with comorbidities require special care, including temporary housing, patient transportation and more to address social determinants of health conditions. Arroyo Vista demonstrates successfully leverages the power of informed clinical decision-making to manage effective care for a target audience. “
The Los Angeles Network for Enhanced Services (LANES) is a regional health information exchange (HIE) serving more than 34 hospitals and health systems and more than 500 community clinics and medical offices serving residents of Los Angeles County. Medi-Cal providers can access 2021 Cal-HOP funds to access LANES. Connect with us on Twitter and LinkedIn or visit the LANES website for more information.
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SOURCE Los Angeles Advanced Services Network
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