Southside medical homes network

linking emergency department patients to community care.

Marr Amy, Tyson Pillow, Stephen Brown

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

BBACKGROUND The 14 neighborhoods surrounding University of Chicago Hospitals (UCH) have both Chicago's highest "ambulatory-care-sensitive condition" hospitalization rates and lack of community-based care. To address these problems, in 2004, the Southside Medical Homes (SMH) Network began linking emergency department (ED) patients with 18 community providers. The ED-based patient navigator (patient advocate) is an integral component of this network, and both their current and developing roles will be discussed. MMETHODS Six navigators worked in the UCH-ED approached eligible patients that are flagged by the ED electronic tracking system. Patients were offered the services provided by primary-care referral and appropriate dental, mental health, and substance abuse facilities. Appointments were scheduled, and pertinent ED medical data was faxed to the outlying sites. Navigator roles were expanding with SMH to include: (1) focus on frequent user/chronic disease populations such as sickle cell disease where advocates will expedite a multidisciplinary clinic referral; (2) navigator training to better inform patients of the specific benefits a "medical home" provides for preventive and psychosocial care; (3) and improving navigator, and secondarily, patient knowledge, of community resources: health-education sites, vocational programs, advocacy agencies, support groups, etc. RRESULTS/CONCLUSIONS Data through 01 July 2007 show a monthly average of 950 ED patients surveyed and 80% of these accepting follow-up referral services. Of those patients with ED-scheduled appointments (43%) in community clinics, network data shows patients returning to their referred providers: 39% of patients have been -> or = times. The navigator role is evolving with the expansion of SMH to include: (1) frequent-user population referrals; (2) preventive health education; and (3) utilization of community resources.

Original languageEnglish (US)
Pages (from-to)282-284
Number of pages3
JournalPrehospital and disaster medicine : the official journal of the National Association of EMS Physicians and the World Association for Emergency and Disaster Medicine in association with the Acute Care Foundation
Volume23
Issue number3
StatePublished - May 1 2008
Externally publishedYes

Fingerprint

Patient-Centered Care
Hospital Emergency Service
Patient Navigation
Referral and Consultation
Health Education
Appointments and Schedules
Community Networks
Preventive Medicine
Self-Help Groups
Hospital Departments
Sickle Cell Anemia
Ambulatory Care
Population
Substance-Related Disorders
Primary Health Care
Tooth
Mental Health
Hospitalization
Chronic Disease

ASJC Scopus subject areas

  • Emergency Medicine
  • Emergency

Cite this

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title = "Southside medical homes network: linking emergency department patients to community care.",
abstract = "BBACKGROUND The 14 neighborhoods surrounding University of Chicago Hospitals (UCH) have both Chicago's highest {"}ambulatory-care-sensitive condition{"} hospitalization rates and lack of community-based care. To address these problems, in 2004, the Southside Medical Homes (SMH) Network began linking emergency department (ED) patients with 18 community providers. The ED-based patient navigator (patient advocate) is an integral component of this network, and both their current and developing roles will be discussed. MMETHODS Six navigators worked in the UCH-ED approached eligible patients that are flagged by the ED electronic tracking system. Patients were offered the services provided by primary-care referral and appropriate dental, mental health, and substance abuse facilities. Appointments were scheduled, and pertinent ED medical data was faxed to the outlying sites. Navigator roles were expanding with SMH to include: (1) focus on frequent user/chronic disease populations such as sickle cell disease where advocates will expedite a multidisciplinary clinic referral; (2) navigator training to better inform patients of the specific benefits a {"}medical home{"} provides for preventive and psychosocial care; (3) and improving navigator, and secondarily, patient knowledge, of community resources: health-education sites, vocational programs, advocacy agencies, support groups, etc. RRESULTS/CONCLUSIONS Data through 01 July 2007 show a monthly average of 950 ED patients surveyed and 80{\%} of these accepting follow-up referral services. Of those patients with ED-scheduled appointments (43{\%}) in community clinics, network data shows patients returning to their referred providers: 39{\%} of patients have been -> or = times. The navigator role is evolving with the expansion of SMH to include: (1) frequent-user population referrals; (2) preventive health education; and (3) utilization of community resources.",
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N2 - BBACKGROUND The 14 neighborhoods surrounding University of Chicago Hospitals (UCH) have both Chicago's highest "ambulatory-care-sensitive condition" hospitalization rates and lack of community-based care. To address these problems, in 2004, the Southside Medical Homes (SMH) Network began linking emergency department (ED) patients with 18 community providers. The ED-based patient navigator (patient advocate) is an integral component of this network, and both their current and developing roles will be discussed. MMETHODS Six navigators worked in the UCH-ED approached eligible patients that are flagged by the ED electronic tracking system. Patients were offered the services provided by primary-care referral and appropriate dental, mental health, and substance abuse facilities. Appointments were scheduled, and pertinent ED medical data was faxed to the outlying sites. Navigator roles were expanding with SMH to include: (1) focus on frequent user/chronic disease populations such as sickle cell disease where advocates will expedite a multidisciplinary clinic referral; (2) navigator training to better inform patients of the specific benefits a "medical home" provides for preventive and psychosocial care; (3) and improving navigator, and secondarily, patient knowledge, of community resources: health-education sites, vocational programs, advocacy agencies, support groups, etc. RRESULTS/CONCLUSIONS Data through 01 July 2007 show a monthly average of 950 ED patients surveyed and 80% of these accepting follow-up referral services. Of those patients with ED-scheduled appointments (43%) in community clinics, network data shows patients returning to their referred providers: 39% of patients have been -> or = times. The navigator role is evolving with the expansion of SMH to include: (1) frequent-user population referrals; (2) preventive health education; and (3) utilization of community resources.

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