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Patient-Centered Primary Care Collaborative a Key Solution for Healthcare Fragmentation: Medical Home Network

Rationale / Objectives

The health care system in Chicago is provided by disparate entities with little to no communication between them. According to Health Affairs (2010), there is only 42% of visits for acute care are made to family physicians, while the remainder are made to emergency departments (28%), specialists (20%), or outpatient departments (7%). This fragmentation points to an important need to transform patient access to the right care, in the right place, at the right time. Medical Home Network exists to facilitate this transformation in a dramatic way.

Project/Program Description & Major Achievements

Medical Home Network united public and private organizations to improve the health status of people living on the South and Southwest Side of Chicago, using MHNConnect. The system captures approximately 60% of patients’ activity, leading to benefitting the overall health care for almost 200,000 Chicago-area patient.

Lessons Learned

The innovative partnership between primary care providers can help improve communication between healthcare providers and improve health status of vulnerable population in the region of Chicago.

Further Description

Medical Home Network (MHN) is a healthcare collaborative located in Chicago. The Medical Home Network aims to strengthen the health care delivery system and improve the health status of South and Southwest Side Chicago residents by collaborating leaders from 12 health care organizations. MHN is altering the way of delivering health care to Chicago patients through “innovative technology combined with a highly efficient, patient-centered, team-based model of care”. Medical Home Network connected with 20 hospitals and more than 170 primary care entities, utilizing MHNConnect to enable information exchange between health providers and monitor of patient hospital usage by care managers. MHNConnect allows providers and care teams access to real-time and historical patients’ data, plus immediate patient activity alerts, prompting them to log into the system.  The Medical Home Network portal captures approximately 60 percent of patients’ activity as it occurs, benefiting the overall health care for almost 200,000 Chicago-area patients. 1 4

Major Achievements

Medical Home Network was honored by Esperanza Health Centers yesterday receiving the Community of Hope Award in recognition for the positive impact the organization is helping primary care teams make for patients at the southwest side medical center.

Metric

Result

Detail

Hospital visits

10.3% decrease in 7-day hospital readmissions for patients served by La Rabida Children's Hospital in one year  

25% decrease in 30-day hospital readmissions for patients served by Esperanza Health Centers since December 2012

Medical Home Network (2014)  

 

Medical Home Network (2015)

Access improvement

45% increase in timely follow-up visits to a primary care physician after hospital discharge, with some months reaching as high as 45.7%.

The follow-up care target after hospital discharge is 29% for patients served by La Rabida Children's Hospital in one year

130.4% increase in timely patient follow-up visits for patients served by Esperanza Health Centers since December 2012

Cost savings

Decrease in the overall cost of care for each patient since the introduction of the new care model in December of 2012 or patients served by Esperanza Health Centers

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