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.
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. Trainings occur monthly and topics will include: Professionalism in the MA role; Communications; Critical thinking; Organizational and Time Management Skills; Team Based Care; Writing; Chronic disease management and prevention; Health literacy; Customer Service, Medication Management, and Cultural Competency. The trainings also focus on the core competency skills medical assistants need to maintain employment.
The Southside Coalition is implementing a Colon Cancer Screening Project with our members. The goal of the 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 in to their appointment..
In partnership with Keck Medicine of the University of Southern California, we implemented the Healthy Lungs Healthy Life lung cancer screening project for patients between the ages of 50-80 who smoked one pack of cigarettes every day for 20-30 years. The program provides free lung cancer screenings, patient navigation and medical treatment if needed. Smoking cessation classes were implemented at two of our member health centers.
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.
