On a summer day in Chicago, an asthma attack sends a teenager to the St. Anthony Hospital emergency department. As he registers, a care coordinator at Esperanza Health Centers looks up at her computer screen and sees an alert that a patient on her clinical team's panel is in the ED. His health risk had been reassessed the previous year, changing from low to high with a diagnosis of depression, and he has not responded to calls from his primary care team since.

The care coordinator, a young woman who grew up a few blocks from her patient, grabs her bag and heads over to St. Anthony's to see her patient.

Many health systems use care coordinators in their population health efforts, but they often work from centralized hubs or payers' offices. At Esperanza Health Centers, a federally qualified health center founded in 2004 in one of Chicago's most underserved neighborhoods, care coordinators are embedded directly into clinical teams.

And they're equipped with data and technology so they can respond in an instant to one of the most critical and costly episodes in patient care: A visit to the emergency department.

Working through the Medical Home Network ACO and its integrated web portal, MHNConnect, Esperanza receives real-time alerts from 22 participating hospitals as patients register in local emergency departments or are admitted.

"Until MHNConnect, we didn't know when our patients were in the ER " says Andy Van Wieren, M.D., Esperanza's chief medical officer. “They would show back up in the office and we wouldn't know what happened in the ED, if meds were changed, et cetera. We felt we could get better outcomes if we were informed of that information — and if we shared our information with the ER doc or the hospitalist. Now we know they're in the ED before the ER doc sees them."

Since launching its care management model with MHNConnect alerts, Esperanza has achieved a 130.4 percent increase in timely patient follow-up visits and a 25 percent decrease in 30-day hospital readmissions. The trend of expense for the total cost of care for Esperanza's patients, compared to other Medicaid patients in the same geographic area, was reduced by 5 percent over the first two years of the program.

And, says Esperanza's CFO, Wayne Sottile, "the outcomes keep getting better and better."

Outreach builds trust

Immediate care coordination makes a big difference in Little Village, a neighborhood known for its vibrant street life of taquerias and carts selling tamales and chicharrones — and home to the largest Mexican immigrant population in the Midwest. Esperanza cares for 72,000 patients each year, 63 percent of whom are covered by Medicaid and 21 percent of whom are uninsured.

Each patient is assigned a provider, a medical assistant, and a care coordinator. Esperanza employs 10 full-time and 2 part-time care coordinators, who were previously community health workers, medical assistants, or even phlebotomists. Some have undergraduate degrees in social work or psychology; some have a high school degree. Their qualification in common is a shared language and culture with Esperanza's patients — and a warm smile.

"We haven't created a formal requirement for educational background because we look for a friendly person," says Carmen Vergara, Esperanza's director of quality and practice transformation. "The role of the care coordinator is to help patients open up and share their obstacles, so that they can reach an optimal level of health. Many of our coordinators have gone through the same situations and can share their own stories. That opens up patients, too."

And because they're on site in the health center, says Van Wieren, “the patients know their care coordinators. They see them when they come into the clinic and learn to trust them."

At no moment in a patient's life is trusted assistance needed more than a visit to the emergency department. Sometimes the real-time, in-person outreach from a coordinator surprises patients, but surprise soon turns to gratitude.

"They like knowing we care enough to reach out and that they're not alone," Vergara says. And that gratitude becomes a commitment to follow up with a provider, and to follow their subsequent care plan.

"When they do come in the clinic, we do a comprehensive review of everything that happened during the emergency room visit," says Van Wieren, "and what their barriers to care are to continuing success in the outpatient setting."

While the state of Illinois requires risk assessments for every new Medicaid patient, Esperanza goes a step further and repeats assessments annually to catch changes in patients' lives — a lost job, a lost spouse, a diagnosis — that may intensify their need for support and care management.

Then the care coordinators help patients work past barriers, sorting out the byzantine tasks of managing illness in the midst of lives already complicated by poverty, language barriers, and other social determinants of health.

"When there is a challenging diagnosis like cancer," says Vergara, "the coordinator provides a warm hand off to the specialist to be sure that patient is comfortable. Our care coordinator's presence at that appointment tells the patient that it is a place that Esperanza trusts. Then the patient is more likely to follow up with specialty care. And when they're done, they'll come back to their medical home."

Esperanza's approach to care coordination, says Art Jones, M.D, chief medical officer for the Medical Home Network ACO, has “ultimately reduced ED utilization, and cost."

"This is an incredible and holistic program to bridge the gap between ED and outpatient care," says Edwin Boudreaux, Ph.D., vice chair of research for the University of Massachusetts Medical School Department of Emergency Medicine and author of a recent study on effective interventions in the ED. The community-based care coordinators and real-time alerts, he says, “allow Esperanza to capitalize on the motivation the patient has to do something — because no one wants to be in the ED."

Gale Pryor is associate editor of athenaInsight. Photography by Alyssa Schukar for Esperanza Health Centers.