May 22, 2020
Logan chats with Cheryl Lulias, President and Executive Director of Medical Home Network, based in Chicago, Illinois, about how MHN strives to improve care for their most vulnerable patients in Cook County utilizing social determinants. MHN focuses on how care is delivered to to Medicaid recipients and unites healthcare systems and community organizations in providing that care. This comprehensive care model is based on behavioral, medical, and social factors explains Lulias. MHN coordinates care across the continuum, providing seamless communication in patient care, and mobilizing resources for the right patients at the right time, she adds. The result: Costs have been cut by more than $50 million in the last four years. This huge savings is derived from shortening inpatient hospital stays, reducing emergency room utilization, increasing primary care involvement, improving communication, and connecting hospitals to patient’s homes to enhance real-time alert activity. In addition, their screening process focuses on “11 impactable barriers” that include access to food, security, and transportation, which are predictive of medical care costs. When COVID-19 arrived, MHN was able to use social determinants and AI to create effective treament plans. Understanding that this pandemic would strongly affect the elderly, poor, and socially isolated patients, MHN took preventative measures to reduce risk. The MHN care management team has now completed more than 6,000 outreach calls in the COVID-19 era in the hope that ERs would not be overrun and to help patients recognize symptoms and figure out the best treatment. This episode is sponsored by GrandPad, www.grandpad.net; Medical Home Network, www.medicalhomenetwork.org; and Orbita, www.orbita.ai.