LOS ANGELES—March 24, 2021—Arroyo Vista Family Health Center is at the forefront of leveraging health information technology to improve patient care for vulnerable communities. The Los Angeles Network for Enhanced Services (LANES) announced today that Arroyo Vista Family Health Center is effectively utilizing community health data from various sources, including local hospitals, ambulatory sites, and behavioral health centers. This innovative approach allows Arroyo Vista Family Health Center to gain critical data insights through the health information exchange (HIE), which they are concurrently using with the LANES population health enablement tool. This powerful combination is enabling Arroyo Vista Family Health Center to more effectively track and manage the continuity of care delivery, particularly for their underserved patient population, with a specific focus on individuals experiencing chronic homelessness.
Since October 2020, Arroyo Vista Family Health Center has been diligently monitoring approximately 100 high-risk patients who are eligible and enrolled in the California Medi-Cal Health Homes Program (HHP). The Health Homes Program is designed to support Medi-Cal beneficiaries who are managing complex medical needs and chronic conditions. These individuals often benefit significantly from enhanced care management and coordinated services. The program facilitates collaboration between California counties, Medi-Cal Managed Care Plans, and healthcare providers to streamline services and eliminate resource duplication, ensuring patients receive comprehensive and efficient care.
Alex Cotté, MHA, Director of Managed Care Services at Arroyo Vista Family Health Center, highlighted the critical needs of this population. “Homeless individuals inherently meet high-risk criteria. They frequently face multiple chronic conditions and are inherently challenging to reach due to the nature of their circumstances,” Cotté explained. “By having this specific subpopulation readily accessible for tracking within LANES, our dedicated care coordinators at Arroyo Vista Family Health Center can quickly determine if any of their patients have sought care at a healthcare facility in the surrounding area.” This proactive approach is crucial for timely intervention and effective care management.
The care teams across Arroyo Vista Family Health Center’s five federally qualified health centers (FQHCs), which include a mobile medical clinic serving Northeast Los Angeles, rely on LANES to access the most current patient data. This includes vital information such as hospital admissions, discharge details, diagnostic results, and specialist reports. The Health Information Exchange system intelligently flags patients who require prompt intervention and helps identify individuals who are high utilizers of healthcare resources. The overuse of healthcare resources, often manifested in avoidable emergency department visits and hospital readmissions, significantly contributes to waste within the U.S. healthcare system. By addressing these inefficiencies, Arroyo Vista Family Health Center aims to enhance the quality and cost-effectiveness of care.
“Understanding the strong link between social determinants of health and clinical outcomes is paramount,” Cotté stated. “Our primary objectives in utilizing LANES are to actively participate in the Health Homes Program, strengthen our internal resources, ensure we have the necessary tools to effectively assess the health needs of our community, and connect patients with timely and appropriate outreach services.” Arroyo Vista Family Health Center is committed to a holistic approach to healthcare that considers both medical and social factors impacting patient well-being.
Reducing Costly Hospital Readmissions
LANES plays a vital role in enabling Arroyo Vista Family Health Center’s care coordinators to proactively manage their patient population. Whether patients present at the emergency department, are admitted to the hospital, or are discharged from any hospital participating in the LANES network, Arroyo Vista Family Health Center remains informed and responsive.
Hospital readmissions are not only detrimental to patient outcomes but also incur substantial financial burdens on the healthcare system. Furthermore, the transition from hospital to community care presents significant risks for patients, with 30-day readmission rates exceeding 20 percent in some populations. Poorly coordinated care transitions contribute to unplanned readmissions, costing an estimated $20 billion annually in the United States. Primary care physicians often face challenges in coordinating patient care, frequently lacking awareness of when their patients have been hospitalized. By leveraging LANES, Arroyo Vista Family Health Center overcomes these communication gaps.
“We utilize the patient healthcare encounter data captured within LANES as a proactive method to engage with our managed care members and local providers, ensuring appropriate and timely case management,” Cotté explained. “This data allows us to refine an individual’s care plan based on issues identified and confirmed across multiple healthcare facilities.” This data-driven approach allows Arroyo Vista Family Health Center to provide more personalized and effective care.
Strengthening Connections with Community Providers
Arroyo Vista Family Health Center’s expanded network of community provider referrals, facilitated by the use of LANES, has yielded positive outcomes in care coordination for at-risk, underserved populations throughout Northeast Los Angeles.
“Having visibility across different care settings where other clinicians are interacting with our HHP patient enrollees within the LANES network has been incredibly beneficial,” Cotté noted. “These external providers also require access to shared patient data, as they are integral partners in our HHP care coordination process.” This collaborative approach enhances the overall quality of care and ensures a more seamless patient experience.
Ali Modaressi, CEO of LANES, emphasized the impact of this partnership. “At Arroyo Vista Family Health Center, LANES supports critical population health initiatives like the Health Homes Program, where patients with comorbidities require specialized care, including access to temporary housing, medical transportation, and other resources to address social determinants of health conditions. Arroyo Vista Family Health Center effectively demonstrates the transformative power of informed clinical decision-making in managing effective care for a target population.”
About LANES
Los Angeles Network for Enhanced Services (LANES) is a regional health information exchange (HIE) serving over 34 hospitals and health systems, and more than 500 community clinics and medical practices that provide care to the residents of Los Angeles County. Medi-Cal providers can access LANES through the 2021 Cal-HOP funding. Connect with LANES on Twitter and LinkedIn or visit the LANES website for more information.
