Our proven model of care focuses on the whole person

MHN's proven care management model has always focused on whole person health by integrating medical, behavioral and social care. We do not just provide care management but link it to community-based primary care. At the heart of this model is our care teams who are from the communities we serve and provide culturally competent care. Our care teams work to meet patients where they are in order to build trust with patients, which helps them become fully engaged in their care and results in better health outcomes.

MHN model of care: key components

  • Delivery redesign: enabling disparate providers to work together to provide better whole-person care across the continuum.
  • Practice innovation: transforming the way care is managed at the practice level.
  • Patient engagement: building relationships with patients and their care teams that go beyond the four walls of the practice.
  • Closing the disparity gap: increasing access and quality of care for safety-net populations.

Transitions of Care Nurses: Big Connectors for Vulnerable Patients

A vital member of the care team is the Transition of Care (TOC) nurse, whose responsibility is to transfer a patient’s care from one setting or level of care to another — but they do much more. Meet two of MHN's Transition of Care nurses who are making a big impact.

Read their story

Driving delivery redesign

MHN Model of Care

Collaborative, team-based model of care that redesigns healthcare delivery and transforms care management at the practice level.

MHNConnect

Cloud-based portal that supports real-time communication, collaboration and care management.

MHN eConsult

Cloud-based platform enables primary care providers to quickly consult with specialists about a patient's specialty care needs.

MHN Patient Engagement

Building relationships that go beyond the walls of the practice.

Collaborative, team-based model of care that redesigns healthcare delivery and transforms care management at the practice level.

MHN Model of Care

The MHN model of care moves care management to the primary care practice and empowers care managers to work closely with patients to prevent readmissions and improve outcomes. The model creates a structured approach to care management by providing the appropriate tools, processes, staffing and sharing of care plans. Dedicated care teams coordinate their efforts across settings to ensure that healthcare delivery is appropriate and timely.

Innovative technology allows the care team to use a collaborative, team-based approach to care by tracking patients across the health care continuum. In addition, care management at the primary care level help prioritize care coordination, support timely interventions and streamline care transitions.

The process starts with an innovative screening tool, MHN's health risk assessment, which incorporates medical, behavioral and social factors and promotes whole-person care.

This comprehensive approach stratifies patient health risk into high, medium or low risk cohorts, and enables providers to prioritize care, directing resources to the patients that need them the most.

Lowering risk, improving outcomes

MHN evaluates effective care management by its ability to lower patient risk.

Cloud-based portal that supports real-time communication, collaboration and care management.

MHNConnect

Our secure cloud-based portal, MHNConnect, helps providers and care teams connect, communicate and collaborate. It allows disparate providers to exchange information and coordinate patient care across a variety of health care settings.

Real-time alerts are an essential part of MHNConnect, and are exchanged in the context of historical claims and pharmacy data, to trigger event-driven workflows that support timely, whole person care. 

Additionally, real-time alerts help care managers engage complex, high-risk patients in the Emergency Department and support coordinated discharge planning according to the unique needs of each patient.

Providers and care teams have the right information at the right time to drive structured care management, coordinate smooth transitions of care, and facilitate timely follow ups.

The MHN Model of Care is supported by sophisticated technology that integrates disparate healthcare entities and improves care management.

Medical Homes
Patients
Health Plans
Hospitals

Medical Homes

Connects disparate entities in the healthcare delivery system and leverages medical, pharmacy, health risk assessment, care management and real-time data to proactively close gaps in care, inform decision making at the point of care, identify high risk members, and enhance communication around patient follow-up, discharge and care plan activities. Tracks the patient journey, and provides structure, transparency and accountability to care teams.

Patients

Activates and engages patients in their own care through shared decision making and coaching, enabled by dynamic outreach and bi-directional communication channels preferred by the patient.

Health Plans

Integrates diverse and disparate data sources, including payor claims and pharmacy fill data, to establish a complete patient view that informs decision making across care settings.

Hospitals

Real-time hospital admit, discharge and transfer alerts connect hospitals with medical homes to enable effective transitions of care.

The power of real-time alerts

  • Members of Medical Home Network (MHN) are providing underserved patients with the right care at the right time in the right place.
  • Esperanza Health Centers is one of the founding members of MHN.
  • Since joining MHN, Esperanza has achieved 130.4 percent increases in timely patient follow-up visits, 25 percent decreases in 30-day hospital re-admissions, and decreases in overall cost of care.

For Esperanza, the transformation began in December of 2012 when their staff began working with MHN to implement a new model of care and introduce a new care coordination program. The program includes MHNConnect, which provides real-time alerts to primary care providers whenever patients are registered for inpatient or emergency services at a hospital in the MHN community. 

Like all of the participants in the Medical Home Network, Esperanza receives actionable, real-time alerts along with valuable historical data from MHNConnect, which are passed along to assist physicians and their care teams. The information provides a complete and thorough understanding of a patient's health care history and needs.

Traditionally, getting patients in for timely follow-up care is a challenge due to difficulties in coordinating care between hospitals and patients' primary care doctors. The team at Esperanza worked very hard to implement the MHN program, which has produced incredible results going from a baseline follow-up rate of 25.3 percent to as high as 58.3 percent in some months.

"We have seen firsthand the impact that a coordinated and dedicated care team can have on improving patient care. We each have a voice in this process. As Esperanza continues to share our successful strategies and experiences, I am optimistic that each of the medical centers in the Medical Home Network will share in the same level of success. We are all in it together."
- Dan Fulwiler, MPH
CEO, Esperanza Health Centers

Stock Photo

Cloud-based platform enables primary care providers to quickly consult with specialists about a patient's specialty care needs.

MHN eConsult

MHN eConsult helps primary care providers consult with specialists about a patient's specialty care needs.

Primary care physicians use the secure, web-based platform to communicate quickly and easily with specialists about treatment recommendations for patients. After reviewing the provider's question, the specialist can request more information, provide a treatment plan or request a face-to-face meeting with the patient. This streamlined process expedites treatment, reduces unnecessary specialty visits and reduces long wait times.

Building relationships that go beyond the walls of the practice.

MHN Patient Engagement

Good things happen when people are involved in their own care: outcomes are better, readmissions decrease, and most importantly, patients are active and engaged in improving their health.

It starts with providers and patients working together to improve health. Care teams drive engagement by developing relationships with patients that extend beyond the four walls of the primary care practice. They educate patients and include them in the decision-making process so they are more accountable for their own healthcare. Care managers then create a care plan that addresses the needs of each individual and treats the whole person including behavioral and social concerns.

We enable bi-lateral communication and give patients the tools and motivation they need to reinforce care plan goals, monitor progress and adhere to self-care regimens.

By building relationships, care managers get to know their patients and can determine the best way to engage them through a variety of personalized communication channels.