How the Southside Coalition Is Strengthening the Local Safety Net

South Los Angeles Collaborative Specialty Care Access
Health Information Technology
Integrating Care Systems
Patient-Centered Medical Home Transitions
Health Care Reform Outreach and Education
Workforce Development

South Los Angeles Collaborative Specialty Care Access

The Southside Coalition facilitates this coalition of clinics, county hospitals, provider associations, and advocacy organizations to champion more access to specialty care in South Los Angeles.

Today, about 25 percent of visits to a community health center result in a referral for specialty care. In some cases, because of specialty care backlogs at hospitals, patients can wait six months to a year before being seen. Health care reform does not focus on increasing access to specialty care, so community health centers need to be creative in finding more ways to get specialty care for our patients.

The top five specialty care access needs identified for our patients are:

  • Cardiology
  • Podiatry
  • Ophthalmology
  • Gastroenterology
  • Orthopedics

The collaborative has:

  • Expanded podiatric care to uninsured patients and advocated for the hire of a podiatrist at the Martin Luther King, Jr. Multi-Ambulatory Care Center (MLK–MACC).
  • Improved the referral process from member clinics to county facilities by establishing relationships between staff and clinicians at member clinics and Department of Health Services leadership.
  • Hired a Patient Care Navigator to advocate and coordinate care for patients at the MLK–MACC facility. This has resulted in a more effective referral process, assistance with backlogged referrals, and the referral of community members to a primary care home.
  • Conducted primary care physician (PCP) trainings with specialists to expand the PCP scope of work at the medical home, thereby reducing unnecessary referrals to a specialist.

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Health Information Technology

Electronic health records (EHR) are an essential part of integrating care services more effectively for our patients. All Southside Coalition members have begun to implement or have fully implemented an EHR at this time. Members using the same systems are able to share best practices and provide one another with support as needed.

The coalition has also worked with our members to test systems that will enable them to receive real time notice of patient hospitalizations to help improve care coordiantion.

We are looking at ways to extend this coordination to local hospitals and others in the safety net to standardize processes.

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Integrating Care Systems

The Southside Coalition is working to develop an integrated system of care between our members and local community-based hospitals that will result in enhanced care coordination for the patient and improved communication between primary care providers and hospital-based providers.  We conducted a care coordination pilot project in 2014 between our 8 FQHC members and St. Francis Medical Center to provide Patient Navigation services to all of our patients using this hospital.  The project was able to reduce the revisit rate of our patients and connected them back to their primary care providers following a visit to the Emergency Department or Inpatient care.  We are now expanding that model to California Hospital Medical Center. The write up of that program can be found here: Southside_Coalition_Care_Coordination_Report_FINAL

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Patient-Centered Medical Home Transitions

The Southside Coalition is working with its member clinics to facilitate their transitions into NCQA-recognized patient-centered medical homes.  To date 7 of our 8 members have received PCMH recognition.

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Health Care Reform Outreach and Education

Many patients are confused about what health care reform will mean for them and their families. The Southside Coalition employs two Promotoras de Salud and one Community Outreach Coordinator to takeconduct outreach and education to uninsured and insured patients. They work to educate community members at Southside Coalition member clinics, local schools, WIC sites, and other locations that offer an opportunity to reach uninsured families.

They educate the people they reach about the benefits of patient-centered medical homes, how health exchanges  work, and the programs available to them for health care coverage.  We also recruit patients to participate in our Community Action Group which engages health center patients to become informed and empowered advocates for their clinic and community.

Promotoras de salud also educate patients about My Health LA, a Los Angeles County health coverage program for undocumented adults which enables them to receive free primary and specialty care, mental health services, chronic disease management, medication, and emergency treatment.  Southside has developed materials to help aid in the promotion of this program, which can be downloaded in ENGLISH or SPANISH.  We have also developed informational videos for community based organizations and consumers:

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Workforce Development

The ability to recruit and retain primary care physicians, nurse practitioners, and physician assistants is a major challenge for coalition members. Thus, the Southside Coalition is engaged in efforts to improve relationships between local universities and our members. This will provide new opportunities for students to gain access and exposure to community health centers through clinical rotations.

Additionally, the coalition has been involved closely in expanding the number of primary care Health Professional Shortage Area designations in South Los Angeles. This designation enables members to recruit providers and provide loan forgiveness and loan repayment as an incentive for working in a low-income or underserved community.

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Next: The People Our Members Serve

Related:
The Southside Coalition Story
The South Los Angeles Safety Net