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Care Coordination Tool Helps Chicago Medical Organization Reduce Readmissions

October 30, 2015
by Rajiv Leventhal
| Reprints

With the use of a web-based care coordination tool, the Medical Home Network (MHN) collaboration in Chicago has been able to reduce hospital readmissions, the length of hospital stay, and the cost of providing care.

The data from two years of using MHNConnect’s secure care coordination tool (2012-2013) versus a baseline year (2011) reveals that 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, including Rush University Medical Center, caring for 170,000 Medicaid patients in Chicago.

MHNConnect enables providers and care teams access to real-time and historical data, plus immediate patient activity alerts, prompting them to log into the system. As a result, caregivers can make better, more informed decisions at the point of care, and make faster, more coordinated care transitions for patients across wherever they receive care, according to MHN officials. The reach of MHNConnect continues to expand and is currently providing integrated connectivity for 20 hospitals and more than 170 primary care practices. 

As such, according to a press release from MHN, 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.

“This 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 healthcare history and patient use of healthcare services throughout the system,” Anthony Perry, M.D., chief medical officer of Rush University Medical Group, which has been using MHNConnect since its introduction, said in a statement. “Providing that information to the healthcare team empowers them to understand and meet their patients’ needs and make the best healthcare decisions with those patients.”

The incorporation of technology into Medical Home Network’s hospitals and clinics is now being applied to the Medical Home Network accountable care organization (ACO), working with Cook County Health and Hospitals System’s managed care program, CountyCare, garnering similar results, officials say.

“Having access to real-time information and up-to-the-minute details pertaining to each patient’s healthcare utilization is invaluable,” Arthur Jones, M.D., chief medical officer of Medical Home Network and longtime practicing physician on Chicago’s west side, said in a statement. “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 healthcare in Chicago.”

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