How Heartland Alliance Health Improves Patient Engagement and Care Coordination Outcomes for Vulnerable and High-risk Patients

How Heartland Alliance Health Improves Patient Engagement and Care Coordination Outcomes for Vulnerable and High-risk Patients

Heartland Alliance Health is a non-profit, Federally Qualified Health Center (FQHC) dedicated to providing care to vulnerable patients across the Chicago-land area. Heartland Alliance offers a wide range of services that address the root causes of poverty and generate social change, including primary care, behavioral health, and oral health services.

We sat down with Olivia Masini, Associate Director of Clinical Services at Heartland Alliance Health. As a member of the Heartland Alliance Care Coordination Team, Olivia ensures proper care coordination is facilitated to patients across all points of care with the goals of improving quality and patient satisfaction. Olivia discusses some of the care coordination initiatives her team is focused on, challenges they’ve faced in succeeding under these initiatives, and how Bamboo Health helps to improve care outcomes for their patients.

What are some of the care coordination initiatives your organization focuses on?

At Heartland Alliance, our primary goal is to make sure that we’re coordinating care for patients at all points of their care journeys. Over the last six months, we’ve focused on capturing all patient activity to ensure that appropriate treatment plans are provided, and the highest-quality care is delivered. This means that we are not only looking at if patients have appointments scheduled with our providers, but that we’re continuously reaching out to them to maintain engagement. This results in better outcomes— both for our patients and organization.

What challenges has your organization faced in succeeding under these initiatives?

At Heartland Alliance Health, we primarily work with patients who face barriers to care. This includes patients with social determinants of health (SDoH) such as homelessness, those who lack healthcare coverage, or suffer from chronic illnesses such as diabetes, HIV, or other infectious diseases, as well as patients diagnosed with mental or behavioral health disorders. Because of this diverse patient population, some of our biggest challenges are identifying patients in need of our services, and monitoring and engaging with them once they leave our clinics.

Specifically, we have struggled to monitor patients’ hospital and emergency department (ED) care events and typically don’t know about them until long after they’ve occurred. This not only results in missed opportunities for us to actively engage with patients, but unnecessary readmissions, and disjointed care. Lastly, without the centralized patient information that we need, it’s difficult to ensure that our own team of providers is efficiently collaborating with one another on patients and their care plans. As we begin to participate in more value-based care contracts, this is a major challenge for us.

Has Bamboo Health helped play a role in overcoming some of these challenges?

PatientPing (Bamboo Health) played a pivotal role in the early development of our care coordination model. We began using PatientPing (Pings) to monitor a subset of our patient population through a pilot program with the Illinois Health Practice Alliance (IHPA), a clinically-integrated behavioral health network that we are affiliated with, and that had already had a partnership with PatientPing (Bamboo Health). We saw early on the value that the platform provided, and were able to establish care team workflows that best addressed the needs of our patients. We have since expanded our partnership with PatientPing (Bamboo Health) to monitor our entire patient population.

With access to PatientPing (Pings), we have the real-time information that we need about on our patients and their care events. So often in today’s healthcare system, providers are siloed and struggle to see the whole picture of a patient’s care journey. This makes it extremely difficult to ensure that providers are collaborating with one another and unified in their treatment/care plan approaches. PatientPing (Pings) bridges these gaps for us. With access to Pings (real-time patient notifications), we’re notified whenever patients have care events across acute and post-acute care settings. Additionally, we can view patients’ prior care encounters, care team members, and important demographic information. With this information, our team can easily collaborate with one another, proactively engage with patients, and monitor them appropriately.

PatientPing (Pings) has also helped to streamline our hospital and ED workflows. With the High Utilizer Flag, we’re notified of any patients who have presented to the ED three or more times in the last 60 days, as well as patients who are at risk for readmission. This helps us to proactively intervene on patient events to potentially avoid admissions, and prevent readmissions.

Can you tell us about a time where Pings helped you help a patient?

We received a Ping on a patient who presented to a nearby hospital. Our team reviewed the patients’ visit history in PatientPing (Pings) and found that he had been receiving treatment at a nearby Skilled Nursing Facility (SNF). Upon reaching out to the patient, we uncovered that he left the SNF to receive suboxone treatments (a drug used to treat opioid addiction), and was afraid to let the SNF staff know. Since leaving the SNF, the patient had also been living in an abandoned building.

We quickly reached out to the Heartland Alliance Health therapist and primary care physician assigned to this patient to schedule follow-up appointments and began implementing a treatment plan for him. We were also able to transition the patient back to the SNF where he had been receiving care to ensure a more stable care environment, and are working on connecting him with housing for once he is discharged. Without PatientPing (Pings), we would have never known about this patients’ care event, been able to get him reconnected with our staff, or set him up with the care and resources he needed.