City of Longmont Aims to Reduce Unnecessary ER Visits Through Primary Care Intervention and HIEDate: August 20th, 2014Category: CORHIO e-NewsletterTopics: Population Health, Primary Care, Emergency Services
The recently formed Longmont Community Health Network to help patients with complex medical conditions better manage their care with the help of medical history from the CORHIO network.
The Longmont Community Health Network is a community-based health collaborative between the City of Longmont, Longmont United Hospital, Mental Health Partners, five health clinics, Boulder County Public Health and other providers in the area. They recently received a grant from the Colorado Health Foundation to improve care for patients in the community who are having a difficult time managing their health conditions. Often these patients rely on the emergency department for care, when their primary care physician would be a better option.
The organization’s team of health care providers receives referrals from primary care physicians in the community who have patients they are particularly concerned about. Longmont Community Health Network intervenes with the patient and helps get them back on track – whether it be helping with transportation, educating them on their condition and their medications, or getting them to schedule regular visits with their primary care physician to manage their conditions.
Dan Eamon, Emergency Manager with the City of Longmont, who is coordinating the systems behind the health network, explains. “We’re basically a connector. We get referrals for patients with diabetes or congestive heart failure or another complex medical issue, often with behavioral health on top of it. The patients are struggling for any number of reasons. So we do a series of in-home visits and assessments, take those results to a case review team of social workers and physicians, and build a care plan that could also include social resources and patient education.”
Information From the HIE Will Help Drive the Conversation
Many of the patients referred to the Longmont Community Health Network haven’t seen their primary care physician in years, but have been to the emergency department, potentially anywhere in the state. The Longmont Community Health Network plans to utilize the CORHIO network to investigate what’s been happening with their patients to better inform their interventions.
“We plan do investigation through CORHIO to see where they’ve been treated and get a good valid patient history,” says Eamon. “CORHIO will give us a true background on the patient, which is going to be very valuable for us. Then we can do our intervention and have a meaningful transition back to the primary care provider.”