The Los Angeles Network for Enhanced Services (LANES) is a specialized Health Information Organization (HIO) that serves high-need populations in greater Los Angeles. To most effectively support providers treating this population’s needs, LANES has developed a suite of tools in a Collaborative Platform to assist providers in delivering Enhanced Care Management (ECM) services to their highest-need patients, including supporting essential tasks in care management, care transition, and care coordination.
The LANES Collaborative Platform is designed to coordinate care across three domains of care: clinical, mental, and social services. The platform can be accessed through a website portal. The features include:
- Patient ECM roster
- Contact information
- On-location indicators
- Medical, behavioral, and social health records
- Hospital ADT notifications
- Service utilization reports
- Accessible care coordination notes
- Practice coaching support
Patient rosters. One of the most valuable ECM tools LANES offers is its Rosters tool. Local health plans such as L.A. Care, HealthNet, and Blue Shield Promise provide practices with rosters of their ECM-eligible members for use with LANES. Once uploaded, LANES generates a roster of a practice’s entire population of ECM patients that can be used by providers to manage these populations. In addition, practices can use the tool to create additional special-population rosters based on particular health conditions, service utilization patterns, or social health needs.
Contact information. LANES stores patients’ and their families’ most recent and historical contact information. Providers can use LANES’ Demographics to access this information, update contact information in their records, or connect to family members who can help the practice find hard-to-reach patients.
On-location indicators. The indicator shows when a patient is still onsite at a healthcare facility. Providers can use this information to find and connect with hard-to-reach patients, such as those experiencing homelessness or housing instability.
Medical, behavioral, and social health records. LANES’ Patient Synopsis contains patients’ medical, behavioral, and social health data from all participating healthcare organizations, including problem lists, recent labs, and other relevant clinical data. Providers can access missing information for a patient before their visit or to prepare care plans for ECM patients, reconcile patients’ medications against information contained in LANES, and determine when a patient may need support with treatment adherence based on fill dates.
Hospital ADT notifications. LANES’ Smart Alert tool sends providers notifications when one of their ECM patients is admitted to or discharged from a hospital or post-acute care setting. Providers can use this tool to trigger outreach by ECM managers to schedule transition of care visits and to prioritize recently discharged patients for additional support.
Service utilization reports. Another helpful tool for ECM management in LANES are the service utilization reports. LANES’ Timeline tool provides a detailed accounting of a patient’s use of health and social health services over the past six to 12 months. Providers can use Timeline to determine whether a patient has received needed specialty care services, is accessing primary care services, or is using the ED. Providers can then use the information in Timeline to prioritize patients for outreach. LANES also provides population-level utilization reports that administrators can use to assess the need for services and guide staffing and resource allocation decisions.
Accessible care coordination notes. LANES’ Care Note allows any providers involved in a patient’s care to leave brief, free, accessible text notes for other involved providers such as mental health or social service organizations. These notes can be used to identify status as the patient’s ECM provider or sharing additional important information that could aid in coordinating and enhancing care for that patient.
Practice coaching support. Finally, LANES offers Implementation Coaching to its clients through a partnership with LA Net Community Health Resource Network. The practice coach helps providers adopt and optimize their use of LANES tools, shares best practices contributed by other providers, and carries feedback and recommendations from clients back to LANES’ technical team and governance board, allowing LANES to innovate and remain responsive to the needs of its provider and patient communities.
LANES is community-based and community-responsive HIO, focused on the needs of the greater Los Angeles area provider community and its most vulnerable residents. The collaborative platform can assist providers in managing their population of ECM-enrolled and eligible patients, prioritize patients for outreach, access missing patient information, and coordinate care across other providers, making the delivery of ECM services more efficient and effective and helping to improve patient outcomes.
LANES provides the enterprise infrastructure required for the interoperability and sharing of patient records required by the CalAIM program. We are working with health plans and stakeholders to align objectives and enhance the portal features as the ECM program matures and the requirements evolve.
For more information on LANES and its ECM tools, visit our Solutions Page.
