In November 2023 I wrote an article about how the Los Angeles Community for Enhanced Providers (LANES), a nonprofit, Certified Well being Data Group (QHIO) community, was offering knowledge in assist of a number of road medication packages. That work has develop into much more vital through the present wildfire reduction effort. Throughout a latest webinar, leaders from LANES and road medication program Healthcare in Motion spoke about their collaboration.
LANES Chief Medical Officer Ali Zadeh, M.D., stated the group has been working with the Los Angeles County Division of Public Well being, on efforts to assist folks have been impacted by the wildfires. “LANES has been very a lot concerned with evacuation middle assist,” he stated. “We supplied the general public well being nurses with entry to affected person data to help them with ordering and re-filling prescriptions for folk who’ve been impacted and who’ve misplaced their livelihoods, their medicines and different issues as a part of the wildfires. We have additionally been a part of an evaluation that is being performed at DPH, presently evaluating the well being impacts of the wildfires.”
LANES is supporting the trouble of offering knowledge on emergency division inpatient and outpatient visits that relate to bronchial asthma and cardiovascular situations that may be impacted by this sort of wildfire exercise, he defined.
Zadeh then launched Sonali Saluja, M.D., M.P.H., the vice chairman of inhabitants well being and medical director of Healthcare in Motion, the place she oversees medical groups and leads analysis and analysis efforts. She beforehand served because the direct of the Gehr Household Middle for Well being Programs Science and Innovation at USC’s Keck Faculty of Drugs the place she was an Assistant Professor of Scientific Drugs and Hospitalist at LAC+USC Medical Middle.
In her presentation, she harassed that Healthcare in Motion is an virtually solely cell group that cares for homeless and unstably housed sufferers. Its mission is to enhance the lives of individuals experiencing homelessness by means of high-quality and holistic care. Saluja stated the group meets its sufferers the place they’re each actually and figuratively to offer them with medical and social providers. “After I say we actually meet our sufferers the place they’re, we’ll go to them whether or not they’re in tents, RVs, below freeway underpasses, you title it. After I say we meet them figuratively, what I am speaking about is absolutely needing them to realize shared targets about housing and well being. That is actually been such a optimistic expertise for me as a doctor working with sufferers. It has been really a rewarding affected person and supplier dynamic.”
Healthcare in Motion has 19 groups in six counties in California. From inside every van, they’ll do medical care, care coordination and housing navigation. From the medical care facet, they normally have one superior follow supplier, like a PA or an NP, in addition to a medical assistant, RN or LVN. The care supplied ranges from main care and persistent illness administration to OB/GYN, habit/psychological well being care, even acute look after sufferers who want to keep away from going to the ED or pressing care.
“It’s vital to say that we actually present team-based care. We’re all in shut communication with one another, and I believe it actually works nicely as a result of we’re part of the identical group,” she stated.
“From a care coordination perspective, we have now between three to 5 peer navigators per workforce, and that is actually the muscle of our workforce,” Saluja stated. “A lot of them have lived expertise themselves, both being homeless or having struggled with habit up to now. They do all the pieces from arranging transportation, going to appointments with sufferers, getting our sufferers meals and clothes and hooking them up with all kinds of various providers. They usually actually assist to construct belief with our sufferers. They do motivational interviewing to alter well being behaviors. In order that they’re extremely invaluable, and I might say the muscle and the guts of our workforce.”
The group additionally has housing navigators, who can navigate the homeless administration data system to get sufferers plugged into the proper sources. They get funds by means of Cal-AIM for housing deposits and lease. In 2024 they improved the housing standing of 949 sufferers and 279 of these, they have been capable of assist assist into everlasting housing.
Highlighting some outcomes, Saluja stated that Healthcare in Motion recognized 715 sufferers with hypertension within the final six months, and 84% are receiving therapy, in comparison with a nationwide common of solely 63% Relating to psychological sickness, they’ve recognized over 1,100 sufferers with psychological sickness, and 61% are on a prescribed therapy, in comparison with 47% of adults with psychological sickness who’re receiving therapy nationally.
“Our knowledge does not embody remedy, so it is in all probability an underestimate, and we’re hoping to include that sooner or later,” Saluja stated. “And we have now 106 sufferers who’re on long-acting, injectable anti-psychotic medicines, which we discovered to be actually a stabilizing power for a lot of of our sufferers with severe psychological sickness.”
Saluja added that unhoused sufferers are a lot sicker, have poorer entry to care, and the care that they do obtain is very fragmented. “That’s why having a device like LANES is so essential and vital for our capability to look after our sufferers.” The Cedars-Sinai-based medical document they use, known as CS-Hyperlink, is built-in with LANES.
For a latest affected person encouter, Saluja described with the ability to rapidly pull up this affected person’s medicines and see that he was just lately prescribed a bunch of medicines, “which, to me, tells me this affected person in all probability has coronary heart failure and/or liver illness. They’re additionally on a blood thinner. I am very involved about the truth that they’ve lots of co-morbid situations. I’m capable of pull up their discharge abstract, and really properly, on the finish of their discharge abstract, it tells us about points to deal with within the outpatient setting for this affected person.
“With out LANES, we’d be ranging from sq. one. We’d in all probability have needed to duplicate lots of the exams and diagnostics that he already had, which might be costly, it could result in delays in care,” Saluja stated.
“One other factor that LANES is providing, particularly with the combination into our EMR, is alerts about our sufferers admissions. This enables us to achieve into hospitals and EDs to examine on our sufferers. We are able to really name the hospital and say, ‘Hey, earlier than you discharge the affected person, tell us. We may help to arrange.’ We are able to communicate to our sufferers whereas they’re within the hospital, even go to them there, which we do very often. We additionally now are capable of put together for our sufferers’ discharge with medicines, wound care, follow-up visits. It actually has led to a lot smoother transitions of care.”
Saluja ended by sharing a few of Healthcare in Motion’s challenges and potential options it’s exploring. “We now have problem discovering sufferers. We’re exploring new sorts of monitoring units that sufferers are sometimes very smitten by accepting, however do not all the time work as nicely.”
In addition they have challenges with low charges of treatment adherence. “However we’re working with pharmacies that now ship on to sufferers. We now have restricted entry to know-how within the area. Lanes has a cell, pleasant model that we have been utilizing, and we’re very excited for the upcoming LANES affected person passport,” she stated. “We now have challenges with care continuity, however we’re partnering with organizations throughout the sufferers’ care continuum and different road medication organizations. And lastly, we’re searching for extra sustainability and exploring issues like road medication fee charges to assist us try this.”
