Arroyo Vista Family Health Center Improves Holistic Case Management for Underserved Population Using LANES HIE

HIE tracks center’s cohort treated at other healthcare facilities to maintain continuity of care and minimize duplicate resource utilization

LOS ANGELES—March 24, 2021—The Los Angeles Network for Enhanced Services (LANES) announced today Arroyo Vista Family Health Center is leveraging its community health data from local hospitals, ambulatory sites and behavioral health centers. Arroyo Vista is using the health information exchange’s (HIE) data insights concurrently with the LANES population health enablement tool to better track and manage continuity of care delivery activities for its underserved population, specifically the chronic homeless.

Since October 2020, Arroyo Vista has continuously monitored approximately 100 high-risk eligible patients enrolled in the California Medi-Cal Health Homes Program (HHP). HHP serves eligible Medi-Cal beneficiaries with complex medical needs and chronic conditions who may benefit from enhanced care management involving California counties, Medi-Cal Managed Care Plans and healthcare providers. These entities work together to coordinate services to avoid duplication of resources.

“Homeless individuals, by definition, meet high-risk criteria. They often have multiple chronic conditions and are difficult to reach by nature of their condition,” explained Alex Cotté, MHA, Director of Managed Care Services at Arroyo Vista Family Health Center. “By having this subpopulation accessible for tracking in LANES, our care coordinators can determine if any of their patients checked into a healthcare facility within proximity.”

Care teams at Arroyo Vista’s five federally qualified health centers (FQHCs), including a mobile medical clinic, located across Northeast Los Angeles use LANES to access up-to-date hospital admissions, discharges, diagnostic results and specialist reports. The HIE flags patients who need early intervention and identifies high utilizers of healthcare resources. Overuse of healthcare resources, such as avoidable emergency department visits and hospital readmissions, are among the leading contributors to waste in the U.S. healthcare system.

“Understanding the direct correlation of social determinants of health with clinical outcomes, our ultimate goals using LANES is to participate in the Health Homes Program to enhance internal resources including readiness of tools to better assess our population health needs, and link patients to timely and appropriate outreach,” said Cotté.

Impact of costly readmissions and costs

LANES helps Arroyo Vista’s care coordinators stay on top of their patient population whether individuals are seen in the emergency department or admitted to or discharged from any LANES hospital participant.

Hospital readmissions are associated with unfavorable patient outcomes and high financial costs. Moreover, the hospital-to-community transition is fraught with risks for patients, with 30-day readmission rates of greater than 20 percent. Poorly coordinated transitions of care translate to unplanned readmission at an estimated cost of $20 billion annually. Primary care physicians are challenged coordinating patient care, when in many cases, they are not even aware that their patients have been admitted to the hospital.

“We use the patient’s healthcare encounters captured in LANES as a way to engage with our managed care members and local providers to assure appropriate case management,” Cotté said. “We can inform that individual’s care plan if issues are experienced and confirmed at one or more healthcare facilities.”

Connecting community providers

Arroyo Vista’s expansion of community provider referrals resulting from using LANES has led to a welcomed outcome while coordinating care for the underserved at-risk cohort throughout Northeast Los Angeles.

“It’s been extremely helpful to have visibility across venues of care where other clinicians are interacting with our HHP patient enrollees and who are in the LANES network,” Cotté remarked. “These providers need shared patient data too, since they are fully engaged with us in the HHP care coordination process.”

According to Ali Modaressi, CEO of LANES, “At Arroyo Vista, LANES supports population health initiatives like the Health Homes Program where patients with comorbidities require special care along with temporary housing, medical transportation and more to treat social determinants of health conditions. Arroyo Vista successfully demonstrates the power of informed clinical decision-making to manage effective care of a target population.”

Los Angeles Network for Enhanced Services (LANES) is a regional health information exchange (HIE) serving more than 34 hospitals and health systems and 500-plus community clinics and medical practices that administer care to residents of Los Angeles County. Medi-Cal providers can tap 2021 Cal-HOP funding to access LANES. Connect with us on Twitter and LinkedIn or visit the LANES website for more information.

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