The State of Illinois and Medical Home Network partner for improved care coordination

Last week the Illinois Department of Healthcare and Family Services and the Medical Home Network (MHN) announced an innovative partnership that could mean better care and lower cost of care for Medicaid beneficiaries.

MHN is one of the largest collaborations of safety net providers in the country working to deliver better coordinated care to vulnerable populations. Partnership with the State allows MHN to test promising delivery and payment innovations that impact approximately 170,000 Medicaid beneficiaries, who make up just less than 10 percent of the State’s total Primary Care Case Management (PCCM) Medicaid population and 11 percent of PCCM costs. The vast majority of these beneficiaries live on Chicago’s South and Southwest Sides, areas where healthcare is fragmented and health status is generally poor.

In addition to the State, this public-private partnership includes the second largest public health system (Cook County Health and Hospitals System), a renowned academic medical center (Rush University Medical Center), a hospital focused on chronically-ill children (La Rabida Children’s Hospital), three community hospitals, six Federally Qualified Health Centers (FQHCs) and an extensive physician network.

Already, MHN has begun to implement innovative technology called MHNConnect that drives meaningful improvement in care coordination by virtually connecting disparate providers serving the population. MHNConnect, a secure, web-based portal, sends real-time alerts on patient hospital activity to Medical Homes (primary care sites) and makes historical prescription and medical claims data available to providers at the point of care. Doctors’ moments of “if I only knew” are turning into “now I know.”

MHNConnect is an enhanced version of a platform that reduced hospital admissions by 31%, ED use by 34% and increased patients’ visits to their PCP by 29% when applied to an uninsured population in California. The MHN model of care has the potential to deliver better care at a lower cost. MHNConnect and other MHN initiatives are expected to significantly improve critical transitions of care by using real-time information technology to increase the percentage of patients who follow-up with their Medical Home within seven days of a hospital stay or visit to the emergency department (ED). MHN also anticipates reducing the populations’ annual ED visits (approximately 100,000 in a 12-month period) by preventing over 3,000 avoidable visits.

During the first day MHNConnect went live, a MHN Medical Home was able to identify a patient who frequently went to the ED for asthma complications but had not visited his primary care physician or filled a medication that could keep his condition under better control. New information from MHNConnect allowed the Medical Home to identify the patient, contact him to schedule an appointment and begin to manage the patient’s condition at his Medical Home.

Within the first three weeks of using MHNConnect, care coordinators at a second Medical Home were able to successfully schedule timely follow-up appointments after Inpatient Discharges and ED visits for 93% of patients with MHNConnect hospital activity. MHN is encouraged by dramatic results such as these, as well as initial positive feedback from patients and providers.

MHNConnect and other MHN initiatives are designed to improve care coordination, a key to improving quality and reducing cost. MHN expects to reduce total cost of care by 2-4% in year one. If projected savings are realized, the MHN model could serve as a delivery framework to meet the needs of similar communities across the country.

Funded by the Comer Science and Education Foundation, MHN is currently rolling out MHNConnect to additional sites. Read more at http://www.mhnchicago.org/node/21.

Cheryl Lulias
Executive Director, Medical Home Network