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The Community Health Referral Network is a groundbreaking new initiative for the region.
The Sacramento region lacks a system of coordinated care and delivery for low-income and vulnerable residents. The economy and elimination of critical public health services has further impacted an already fragmented health care safety-net. Growing numbers of uninsured and underinsured are turning to hospital emergency departments for the most basic care because they have lost or lack a primary care provider. Capacity exists within the nonprofit community clinic system to provide care, but patients are unable to navigate what has become a very complex health landscape.
The Community Health Referral Network is designed to shift the paradigm. This pilot project was launched in late summer of 2010. It is a collaborative initiative between the hospitals and 18 nonprofit community-based clinics. It connects uninsured and underinsured patients seen and treated in emergency departments for non-urgent/emergent care to appropriate medical homes in the community.
Goals are to:
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Increase access to care by maximizing community health assets
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Improve the health status of the underserved
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Reduce reliance on emergency departments for non-acute care, and
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Lower health care costs
Under this new model, a referral specialist serves as the liaison between hospital and clinic partners and assists patients in finding primary and/or other care after they are discharged from the emergency department. A registry of clinic providers is maintained and includes information on scope of treatment, location, eligibility and cultural competencies, in order to match patients with care that best meets their specific needs.
MobileMD is providing the technology solution needed to more effectively facilitate and enhance the care coordination process. It enables multi-directional communication among partners in order to expedite patient referrals, make and confirm appointments, securely exchange administrative and patient health data in real-time, and track patient outcomes.
Use of MobileMD health information technology exchange between hospitals and the community clinic system is groundbreaking for the Sacramento region.
Program outcomes early in the project demonstration phase are promising. On average:
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40 to 50 patients are contacted each day
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15 or more patient appointments are confirmed each day, depending on clinic response time
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Patient show rates for clinic appointments are ranging from
70 to 80%
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Patient follow up indicates 75% of patients are satisfied with care received in the community clinic setting
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