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South LA program will attempt to fill 'gaping hole' between hospital and primary care

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For South L.A. patients, the transition between hospital-based care and follow-up services in a primary care setting can be difficult. Around early July, a new program from the Southside Coalition of Community Health Clinics will attempt to smooth out that transition.

A new program will attempt to help bridge the gap between primary and hospital care for South Los Angeles patients, who all too often "get lost in the system."

That's according to Nina Vaccaro, the executive director of the Southside Coalition of Community Health Centers. The group, which is comprised of eight federally-qualified health centers in South L.A., is developing a program that would place two "care coordinators" at St. Francis Medical Center in Lynwood. The goal is to help area patients navigate the often-confusing transition between hospital-based care and primary care to get the follow-up services they need.


The eight member clinics of the Southside Coalition of Community Health Centers (in blue) and St. Francis Medical Center (in red).
 

Vaccaro said there's currently a "big, gaping hole" where that transition should be.

"We're looking at how do we help improve care transitions from primary care to the hospital, then back to primary care," she said.

Here's how the program would work: The Southside Coalition will set up an electronic alert system at St. Francis, which will contact the two care coordinators when a patient from one of the eight member clinics has been admitted. A coordinator will find that patient before discharge to not only help set up follow-up appointments with a primary care provider, but to make sure that patient's primary care provider has the information – charts, labs, results – needed to provide effective follow-up care.

It's pretty straightforward, and while it's not exactly simple to set up, Vaccaro did call it a "no-brainer."

"One of the things we have to really be mindful of is just making sure that patients understand what a medical home is for primary care," she said, referring to a situation in which a patient has "one relationship with one primary care doctor."

"We know that patients can be a little migratory in where they seek health care services," Vaccaro added. "If there's a wait at one clinic, they'll go to the other one."

That's less than ideal, because it interrupts the consistency of care. Vaccaro said it's best for a patient to have a medical home, but also acknowledges "it's not an easy thing to do."

That difficulty is often what drives people to the emergency room for conditions that aren't necessarily an emergency. That's why another goal of the program is to educate South L.A. patients on when to go to the E.R. and when to see their primary care provider, and to get "high-utilizers" of the E.R., as Vaccaro calls them, into a primary care provider's office more often.

"Unless we're doing a really good job of some of the hand-holding and trying to explain at what point you access the right care at the right time, that cycle of [E.R. use] is going to continue for those patients," she said.

It helps, she added, that the Affordable Care Act will eventually incentivize hospitals to reduce expensive "preventable readmissions" by way of a financial penalty.

"I think the end result is we've got a system of care where we can demonstrate that patients are not getting lost in the system," said Vaccaro. "We've got folks on both ends that are there, waiting to catch a patient, helping them get the right services at the right time."

The Southside Coalition hopes to implement the program, which is being funded by the Blue Shield of California Foundation, by early July. If it's successful, it may be replicated at California Hospital Medical Center or Martin Luther King, Jr. Community Hospital when it opens next year.

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