Medical Home Network's new model of patient-centered care for Chicago's safety net patients proving effective at La Rabida

Melanie Maeda is one of the new health care professionals making a difference on the front lines of safety net health care in Chicago. Maeda's title is Care Coordinator at La Rabida Children's Hospital, where she has worked for nearly two years, as part of Medical Home Network's initiative to help Medicaid patients from some of the most underserved neighborhoods in Chicago to get the right care, at the right time, in the right place.

Medical Home Network is a Chicago-based health care collaborative devoted to transforming health care delivery for Chicago Medicaid patients by fostering collaboration and innovation among safety net providers.  Health care providers, like La Rabida, work directly with Medical Home Network to implement a new model of care, which is anchored by care coordinators who combine the efforts of institutions and leverage unprecedented virtual connectivity and technology to benefit the overall health care for almost 200,000Chicago-area Medicaid patients.  Care coordinators, like Maeda, play an important role throughout the Medical Home Network community, which includes 16 hospitals and more than 150 primary care medical home sites.

One of the objectives is to change the health care habits of patients who continually rely on emergency departments.  Reports from La Rabida are already showing the effectiveness.  Over the past year, La Rabida has gained a 145 percent increase in timely follow-up visits to a primary care physician after hospital discharge, with some months reaching as high as 45.7 percent. The follow-up care target after hospital discharge is 29 percent.  As a result, there has been a 10.3 percent decrease in seven-day hospital readmissions.

Those results would not be possible without care coordinators utilizing Medical Home Network's portal to receive real-time alerts along with real-time and historical data.