Medical Home Network's new model of coordinated care achieves ground-breaking results at Esperanza Health Centers

Medical Home Network announced today the results of a data review of its model of care program for Illinois Medicaid patients as implemented at Esperanza Health Centers' three primary care practice sites in Chicago's Little Village neighborhood on the southwest side, which shows as high as a 130.4 percent increase in timely patient follow-up visits, 25 percent decrease in 30-day hospital readmissions, and a decrease in the overall cost of care for each patient since the introduction of the new care model in December of 2012.

According to the review, Illinois Medicaid patients who were a part of Medical Home Network's program and visited their assigned primary care physician at Esperanza Health Centers within seven days after being discharged from the hospital or Emergency Department, increased from a 25.3 percent pre-implementation baseline to as high as 58.3 percent in certain months, with Esperanza's first intervention year averaging a 47.2 percent follow-up rate. The monthly-high of 58.3 percent represents a 130.4 percent increase over the pre-implementation baseline. In addition, hospital readmissions within 30 days of patient discharge decreased from 11.2 percent to 8.4 percent post-intervention, a 25 percent reduction in readmissions.

"We set an ambitious goal of reaching a 29 percent follow-up rate and in some months they have achieved more than 58.3 percent, more than double our goal," said Cheryl Lulias, president and executive director of Medical Home Network. "These are incredible, ground-breaking results by the team at Esperanza. They adopted the new model of care and exhibited the flexibility to transform their practice, which is what produced those results."

The Medical Home Network target for follow-up care with a primary care physician after hospital discharge is 29 percent. Traditionally, getting patients in for timely follow-up care is a challenge due to difficulties in coordinating care between hospitals and patients' primary care doctors. Each of the founding Medical Home Network partners at the six hospital systems and their physician practices plus the six Federally Qualified Health Centers (totaling more than 12 hospital sites and 120 primary care practice sites in Chicago and suburban Cook County), are collaborating to achieve that goal and to transform care coordination.  Esperanza Health Centers, one of the founding partners of Medical Home Network, identified the key factors to not only achieving that goal, but surpassing it.