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

Care coordination technology & real-time alerts boost follow-up care by 130.4 %

CHICAGO December 11, 2014 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 [with a primary care physician after hospital discharge] 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.”

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