Since its implementation in 2012, a medical home for Medicaid patients showed a 130.4 percent increase in timely patient follow-up visits, a 25 percent decrease in 30-day hospital readmissions, and a decrease in the overall cost of care for each patient, according to the Medical Home Network.
llinois Medicaid patients who were a part of Medical Home Network’s program and visited their assigned primary care physician (PCP) at Esperanza Health Centers (three primary care sites in Chicago) within seven days after being discharged from the hospital or emergency department (ED) increased from 25 percent to as high as 58.3 percent in certain months, with Esperanza’s first intervention year averaging a 47.2 percent follow-up rate. 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. These results more than double the researchers’ original goal, officials say.
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 (FQHCs) 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.
In December 2012, Esperanza worked with the 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 that 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’ healthcare utilization and needs. After six months, the Esperanza team could see the inherent value of the Medical Home Network system, but realized it would require a full-time professional to coordinate care among providers and patients.
Given the influx of data and ability to identify discharged hospital patients in need of appointments with their PCP 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.
Source: Medical Home Network, December 11, 2014
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