Family health

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

LOS ANGELES, March 24, 2021 /PRNewswire/ — The Los Angeles Network for Enhanced Services (WAYS) announced today Arroyo Vista Family Health Center leverages its community health data from local hospitals, outpatient sites, and behavioral health centers. Arroyo Vista uses Health Information Exchange (HIE) data alongside the LANES population health activation tool to better track and manage business continuity of care delivery for its population underserved, especially the chronically homeless.

Because October 2020Arroyo Vista has continuously followed approximately 100 eligible high-risk patients enrolled in the California Medi-Cal Health Home 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.

“Homelessness, by definition, meets high risk criteria. They often suffer from multiple chronic conditions and are difficult to reach due to the nature of their condition,” explained Alex Cotté, MHA, director of managed care services at Arroyo Vista Family Health Center. “By making this subpopulation available for tracking in LANES, our care coordinators can determine if any of their patients have checked into a nearby healthcare facility.”

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

“By understanding the direct correlation between the social determinants of health and clinical outcomes, our ultimate goals in using LANES are to participate in the Health Homes program to improve internal resources, including the availability of tools to better assess health needs. of our population and connecting patients to timely and appropriate outreach,” Cotté said.

Impact of costly readmissions and costs

LANES helps Arroyo Vista Care Coordinators stay on top of their patient population, whether individuals are seen in the emergency department or admitted or discharged from any LANES hospital attendee.

Hospital readmissions are associated with adverse patient outcomes and high financial costs. Moreover, the transition from hospital to community is fraught with risks for patients, with 30-day readmission rates exceeding 20%. Poorly coordinated transitions of care result in unplanned readmission at an estimated cost of $20 billion annually. Primary care physicians struggle to coordinate patient care, when in many cases they don’t even know their patients have been admitted to 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 ensure appropriate case management,” Cotté said. “We can notify that person’s care plan if issues are encountered and confirmed at one or more health facilities.”

Connect community providers

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

“Having visibility into points of care where other clinicians interact with our HHP enrolled patients and who are part of the LANES network has been extremely helpful,” Cotté noted. “These providers also need to share patient data, as they are fully engaged with us in the HHP care coordination process.”

According to Ali ModaressiCEO of LANES, “At Arroyo Vista, LANES supports population health initiatives such as the Health Homes program where patients with comorbidities require special care as well as temporary housing, medical transportation and more to treat patients. social determinants of health conditions Arroyo Vista successfully demonstrates the power of informed clinical decision-making to effectively manage the 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 more than 500 community clinics and medical practices that administer care to residents of Los Angeles County. Medi-Cal providers can operate 2021 Cal-HOP Funding to access the LANEs. Join us on Twitter and LinkedIn or visit the LANES website for more information.

Media Contact:

LANE contact:

Angela Jenkins

Brad Hibard

Angela Jenkins & Associates LLC for LANES

Strategy Director



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SOURCE Los Angeles Network for Enhanced Services

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