Before the Affordable Care Act was enacted in 2010, the Medical Home Network health information exchange was forming in the Chicago metropolitan area with a focus of improving care for high-risk Medicare and Medicaid patients.

The network went live in February 2011, and today, 22 hospitals, more than 200 clinics and 1,600 primary care providers are linked to the network to serve 150,000 vulnerable individuals in Cook County.

Over time, the network has expanded services and now is looking at taking what may be its biggest step—going mobile. But it will take a little while to get there, says Cheryl Lulias, its president and executive director.

Since July 2014, the network has transmitted more than 16 million real-time alerts, facilitated about 1,300 follow-up appointments monthly and supported 100,000 transitions of care. The network also serves 9,000 detainees at the Cook County Department of Corrections.

Medical Home Network uses a secure web-based portal it developed with an unidentified vendor to share information with hospitals and physicians, generating a real-time alert if a patient is hospitalized, and notifying the patient’s physician and care coordinator.

“The goal is to enable the right information at the right time to drive appropriate intervention and action, and to get a complete picture of the patient,” Lulias says.

The network uses data analytics to assess historical claims data and sends electronic alerts to physicians and care managers when necessary, turning information into actionable and prioritized tasks, Lulias adds.

The analyzed data, for instance can notify a physician practice that a patient—for example, a high-risk diabetic—has not been taking prescribed medications and now is in the emergency room, so the practice’s care manager can go meet the patient in the ER and start an intervention program to keep him or her out of the ER.

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Use of the network at Esperanza Health Centers has resulted in a 130 percent increase in timely patient follow-up visits, a 25 percent decrease in 30-day hospital readmissions and a decrease in the overall cost of care for the centers, according to CEO Dan Fulwiler.

“More than half the residents in our service area experience significant economic, educational and health disparities,” Fulwiler says. “Our partnership with Medical Health Network has been invaluable in improving health care delivery for our patients.”

By the end of 2016, Medical Home Network was ready to push physical boundaries further by expanding he network to sub-acute care and other ancillary providers, as well as community organizations.

Care teams now can proactively reach out to individuals and send them text messages, such as encouraging the scheduling of a physician appointment, as long as the individual has a computing device and Internet connectivity.

Medical Home Network also can push information out describing patients’ social factors that clinicians, care managers, ancillary providers and community organizations should be aware of, such as a patient with housing instability issues or behavioral health needs, in an effort to provide whole-person care, Lulias says.

Another new initiative is to develop standard workflows to better communicate with various organizations across the region. “When you share information you facilitate conversation across organizational and physical boundaries and start to break down the silos,” Lulias adds.

On the horizon is a much bigger step—moving to mobile apps to enhance patient engagement. The project is in the development phase, with much work to be done, Lulias says, but an early task may be looking at how best to reach patients and connect them and caregivers across the ecosystem.

Going mobile, she adds, will enable coaching, patient self-management, bi-directional communication with the care team, improved decision making, patient engagement and making the patient part of the care team.

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