Medical Home Network achieves significant decrease in hospital readmissions and increase in follow-up care through innovative care coordination exchange

CHICAGO, Oct. 15, 2015 /PRNewswire/ -- In Chicago, Medical Home Network is changing the way health care is being delivered to Medicaid patients through innovative technology combined with a highly efficient, patient-centered, team-based model of care.

This model is being implemented in concert with MHNConnect, a secure web-based care coordination tool that allows real-time data sharing between various entities, like hospitals and primary care practices, effectively connecting care coordinators across the city and bridging gaps in care.  As the first technology of its kind to be implemented across disparate entities in Illinois, MHNConnect now enables providers and care teams access to real-time and historical data, plus immediate patient activity alerts, prompting them to log into the system.  This marks a major improvement in health care, resulting in better, more informed decision-making at the point of care, plus faster, more coordinated care transitions for patients across the continuum. 

The reach of MHNConnect continues to expand and is currently providing integrated connectivity for 20 hospitals and more than 170 primary care practices. 

"MHNConnect's connectivity is transforming the way providers collaborate to deliver better care at a lower cost," said Cheryl Lulias, president and executive director of Medical Home Network. "This care model is transforming the way health care is delivered because we are now breaking down the four walls of the doctor's office and extending care delivery to our patients and the entire health care community linked on MHNConnect."

An examination of the data from two years of MHNConnect's implementation (2012-2013) versus a baseline year (2011), reveals there was a significant decrease in hospital readmissions and a substantial increase in timely follow-up visits with primary care doctors among the pioneer early-adopters - specifically six Federally Qualified Health Centers and six hospital systems caring for 170,000 Medicaid patients. Comparing performance year one (2012) to the previous year (baseline), Medical Home Network's partner hospitals and clinics recorded a 12.4 percent reduction in hospital readmissions (within 30 days of being discharged) in year one and 24.8 percent reduction in year two (2013). The number of inpatient hospital days decreased 3.7 percent from baseline in year one and 24.4 percent from baseline in year two. The average length of stay decreased 5.1 percent from baseline in year one and 20.2 percent from baseline in year two.  Finally, the cost of care per member per month, decreased 3.3 percent from baseline in year one and 5.0 percent from baseline in year two.

"Data has proven MHNConnect to be a highly efficient and reliable care coordination tool, giving care teams access to their patients' pertinent information and activity, which helps provide a better understanding of the health care history and utilization throughout the system," said Anthony Perry, MD, chief medical officer of Rush University Medical Group, which has been using MHNConnect since its introduction. "Providing that information to physicians empowers them to understand and meet their patients' needs and make the best health care decisions for those patients."

The extended care delivery facilitated by MHNConnect is exemplified by the story of a 34 year-old man, who up until the introduction of the Affordable Care Act, had no medical coverage. After January of 2014, he was assigned to Rush University Medical Group for his primary care. A nurse care coordinator received a real-time alert, logged into the portal, and was able to track his health care usage in the MHNConnect system. The man, who suffers from COPD, diabetes, and sleep apnea was in and out of the emergency department at several hospitals in order to receive care.  The care coordinator was able to contact the man and assign him to a primary care physician for his overall care, a pulmonologist for his COPD and dietician for his diabetes.  Two days later, she was surprised to receive a MHNConnect real-time alert saying he was in Stroger Hospital's emergency room. He was there to get his blood pressure and glucose levels checked. At this point, he didn't realize that he could have contacted, or even walked into, his medical home at his primary care clinic. The nurse explained this to him and he is now on track to improve his health care, knowing he has a care team he can access at any time.  The nurse worked with him to establish a plan and for the first time in his life, he has a health record that his doctor, specialists and care team can review in order to best help him.

The example of this man's improved patient experience, and reduced reliance on Emergency Room care, is part of a growing trend brought about in large part by the providers and care teams who have adopted the use of MHNConnect.

"Having access to real-time information and up-to-the-minute details pertaining to each patient's health care utilization is invaluable," said Arthur Jones, MD, chief medical officer of Medical Home Network and longtime practicing physician on Chicago's West side. "Analysis reveals that now, for each Chicago Medicaid patient going to the hospital for a health problem, one out of every three will make a follow-up visit to their primary care physician after hospital discharge. That's a big step in the right direction for health care in Chicago."

The successful incorporation of technology into Medical Home Network's hospitals and clinics is now being applied to the Medical Home Network (MHN) ACO, working with Cook County Health and Hospitals System's managed care program, CountyCare, garnering similar results and signaling the future use of technology to deliver affordable and efficient quality health care.       

About Medical Home Network
Medical Home Network is a Chicago-based health care collaborative devoted to transforming health care delivery for Chicago Medicaid patients by fostering collaboration and innovation among safety net providers.  The Medical Home Network collaborative consists of leaders from 12 health care organizations, who continue to have an equal voice in the decision-making process. In addition, Medical Home Network has grown its connectivity to 20 hospitals and more than 170 primary care entities, using MHNConnect to enable information exchange among providers and monitoring of patient hospital utilization by care managers. The Medical Home Network portal captures approximately 60 percent of member patient activity as it occurs, benefitting the overall health care for almost 200,000 Chicago-area Medicaid patients. More information is available at www.MHNChicago.org.

SOURCE Medical Home Network

Related Links

http://www.MHNChicago.org