Introduction:
Throughout 2024, LANES partnered with Alta-Prospect Health System, a network of six Los Angeles County hospitals, to support its Coordinated Regional Care Group (CRC). CRC uses a data-driven approach to manage the needs of 130,000 Medi-Cal beneficiaries facing complex health challenges, including chronic conditions and issues related to housing, transportation, food insecurity, and employment. In 2024, Partners In Care Foundation (Partners), a social service referral partner of Alta-Prospect, also joined LANES. CRC leveraged the LANES platform to streamline patient referrals to Partners, further enhancing care coordination for those in need.
Background:
LANES collaborated with CRC and Partners to enhance care coordination with three key objectives:
- Improve Care Coordination: Achieve better outcomes for ECM patients enrolled in CRC.
- Reduce Unnecessary Returns to Acute Care: Minimize avoidable readmissions.
- Implement a Closed-Loop Referral Process: Launch the first phase of the referral system from CRC to Partners. Previously, this manual, time-consuming process sometimes resulted in eligible patient files not being sent or getting lost in follow-up.
Phase 2 of the project will begin in 2025, with Partners fully closing the loop by sharing care plans and service updates with CRC, further enhancing coordination between the agencies.
Methodology:
LANES collaborated closely with CRC clinical team and Partners leadership for workflow integration and measuring improvements using the following strategies:
- Patient Identification & Tracking: Identified patient cohorts and developed rosters to monitor patients admitted to inpatient via LANES Smart Alerts.
- Training & Platform Utilization: Trained clinical and care support staff to access the LANES portal, enhancing care coordination and treatment decisions.
- Regular Progress Meetings: Conducted bi-weekly or monthly meetings with participants to review progress and adjust workflows as needed.
- Chart Reviews & Utilization Analysis: Performed detailed chart reviews on selected patients to analyze utilization trends and detect recurring patterns for targeted interventions.
- Stakeholder Collaboration: Facilitated collaboration between CRC and Partners to support the referral process for patients receiving care from both providers. Utilized the LANES “notes” feature to capture and share critical information across care teams.
- Comprehensive Data Retrieval: Assisted participants in retrieving key reports on ED and inpatient usage, to identify “high utilizer” patients for interventions.
Educational Initiatives: Weekly “lunch and learn” sessions to sharpen participants’ skills, using best practices.
Results:
The project’s goal was to reduce patient recidivism and acute care returns among Medi-Cal beneficiaries with complex conditions. A pre- and post-implementation analysis revealed a 68% reduction in inpatient visits among CRC ECM eligible or enrolled patients over one year. Notably, even with increased CRC enrollment from 2023 to 2024, there was a significant overall decrease in inpatient acute care usage for this population.
Conclusion:
The reduction in readmission to acute care for this vulnerable, underserved population highlights the success of the collaboration in improving care coordination. These results underscore the critical need for community-based organization (CBO) support services, which can be addressed through more efficient referral processes, a technology-driven approach, and continued care coordination support offered by LANES.
