The Southside Coalition in partnership with Dignity Health-California Hospital Medical Center implemented a care coordination programs that enables a team of patient navigators working on-site at the hospital to receive real-time notifications through a health information exchange system when any patients from our member health centers have been registered in the Emergency Department or admitted at the hospital. The goals of the program are to enhance care coordination by ensuring that patients receive timely follow-up care in order to improve health outcomes and reduce hospital and emergency department readmissions. This program is helping close the communication gap in patient care to assure that community health center primary care providers are informed when their patients are seen at the hospital or the emergency department and enables both the clinic and hospital care coordination teams to work collaboratively. Since the implementation of the program in 2016, over 7,000 patients have been served.
Our Promotoras de Salud and Community Outreach Coordinators provide targeted outreach, education and referrals to uninsured individuals at Southside Coalition member clinics, schools, community colleges, community-based organizations, and community events. The purpose of the program to educate about health coverage and insurance options provided through the Affordable Care Act or locally in LA County and to connect patients to a medical home if they do not have one. Additionally, our staff is educating patients on the importance of appropriately using a medical home.
Southside staff assist our member health centers by engaging with patients who are due or past due for annual physicals; well-child exams; immunizations, and colon, breast, and cervical cancer screenings by calling them to schedule appointments with their primary care providers. Southside staff also educate
patients on the importance of receiving care from their doctor on a regular basis.
The Southside Coalition of Community Health Centers implemented a professional development training program for Medical Assistants working at the Southside Coalition member clinics. The goal of program is to engage and provide training for Medical Assistants by giving them the tools needed to carry out their professional responsibilities; continue their professional development; and encourages them to continue working in underserved communities. The training program focuses on both the clinical and nonclinical soft skills medical assistants need to be effective members of community health center care teams.
The goal of the Colon Cancer Screening Project is to provide education and awareness about colon cancer and the importance of colon cancer screenings and to increase colon cancer screenings for eligible patients. This will be accomplished by increasing outreach and education efforts at each health center; calling patients who are due for a screening or behind on their screenings to schedule an appointment and providing FIT tests to those patients prior to their appointment so they can bring it to their appointment.
The Southside Coalition hosts convenings that bring together primary care, behavioral health and substance use treatment providers to discuss ways to collaborate, improve, and increase the integration of primary care and behavioral health services in SPA 6. The goal of the summits are to forge new collaborations, partnerships and opportunities for networking that will further enhance integration of primary care services, mental health and substance use services in SPA 6.