Los Angeles Network for Enhanced Services (LANES) is a nonprofit health information network with data on more than 10 million patients. During a recent webinar, two physicians working with people experiencing homelessness described how LANES brings patient data together from different sources to help them address the needs of their patients.
Ali Zadeh, M.D., chief medical officer of LANES, began the presentation by noting that
there are over 350 ambulatory practices, almost 50 Federally Qualified Health Centers and community health centers comprising 250 sites and almost 40 hospitals, on the network, as well as health plans such as LA Care, Health Net, and Blue Shield of California and post-acute care organizations.
Zadeh introduced Shayan Rab, M.D., associate medical director of field-based services for the Los Angeles County Department of Mental Health, who noted that people experiencing homelessness often get disjointed care, and more effort needs to be put into recovery plans with resources to support plan implementation.
Rab is a supervising psychiatrists overseeing the county's Home Team, a multidisciplinary field-based team that serves individuals with severe mental illness who are experiencing chronic unsheltered homelessness. These are the sickest of the sick. “We are at the highest level of care on the streets, which means that we take care of folks who have had neglected mental health needs in the system for decades,” Rab said. “They're oftentimes super-impaired. Their mental health symptoms are so impaired they can barely provide for their food, clothing or shelter on the street.”
The Home Team uses LANES to create an ecosystem of recovery, Rab said.
“Our job is to take these folks who are that impaired and transform their lives and reintegrate them into the community with housing and community support structures in place. The Home Team's job is longitudinal recovery from community disconnection to community reintegration with housing and treatment onboard.”
When Rab started working with the Home Team, it had about 70 team members. It has now grown to 160 team members with 15 street psychiatrists spread across LA County. It serves about 1,700 individuals.
Rob explained a little about how the traditional mental health system is divided into buckets: outpatient, inpatient, and emergency rooms. These different areas are not integrated. They oftentimes have their own EHRs. They have their own policies and procedures. They have their own firewalls in terms of sharing information. “If you are either housed or you have a strong support network, you might be able to move across these different levels of care with some ease because at least you can get information for one level of care share that information with the other level of care and have some continuity,” he said. The problem arises if you are chronically homeless. “You might be getting fragmented care across all of these different levels of care and there is no one longitudinal record that pulls all the information into one centralized space and shares that information in a supportive way where you can get an idea of what someone's health needs really are,” he said.
“We have to build an ecosystem of recovery that weaves together all of these resources through partnerships, through clinical partnerships, through information-sharing partnerships, and an understanding of what your overall goal is,” he said. “The time for operating in silos is gone. If you want to help someone who is experiencing homelessness, you have to be a part of an ecosystem of recovery where everybody has a shared vision for what the client needs.”
Rab explained how the Home Team typically works. If an individual with severe mental illness is experiencing homelessness, the Home Team responds. They will get a referral from other outreach teams, first responders, law enforcement, or inpatient units.
“We go out and connect with this individual,” Rab said. “This is where LANES comes in. When we identify a referral, we quickly check LANES to see what their past psychiatric history is and how many times they've been admitted in the past. What kind of medical conditions should we be paying attention to? What kind of prior medication trials they've had? Do they have a substance use history? Should I be worried about fentanyl use with this person? Are there any family members that we can call and reunite this person with a lost loved one? What about their social history? What kind of skills do they have if we're trying to rehabilitate them? We're going to get vital signs when we see them in the field, but what's their pattern of vital signs over quite some time? And has there already been a lot of recent medical workup, laboratory workup and imaging that we can use to kind of catapult them into housing a little bit faster rather than trying to recreate the wheel and getting an entire new panel of labs if one was just done recently?”
An example of one of the times Rab used LANES was with an individual who was unresponsive and appeared a little bit confused. “He had a little hospital tag on him that mentioned his name and his date of birth. That's when I was able to pull up LANES on my phone, which allowed me to check his medical history and find out that this person had a seizure disorder,” he recalled. “I was able to call an ambulance and give them an appropriate report on what I thought was going on. I thought he had a seizure and needed to go to the hospital.”
“While Home Team builds all of these clinical partnerships, the information-sharing partnership is built with LANES and it allows us to create this ecosystem of recovery where we can take individuals, activate the entire ecosystem, get them to whatever resources they need, but ultimately move them into the housing pipeline and get them off the street and work towards community reintegration,” Rab said. “And that is what we have been able to do for the Home Team ecosystem by including LANES into our model of care.”
Housing for Health
Emily Thomas, M.S., M.D., is medical director of the Star Clinic, part of the Los Angeles County Department of Health Services. The clinic has more than 1,200 assigned patients, 60 percent of whom are in supportive housing through the Housing for Health program. The clinic provides enhanced care management services to more than 200 patients to integrate high-quality clinical care with housing opportunities.
Thomas explained that Housing for Health was founded in 2012. “We're a relatively young county organization — just over 10 years old — and we're nimble, which I appreciate. We essentially contract with homeless service agencies across the county to provide street outreach to provide interim housing, to provide opportunities for permanent supportive housing. We have over 18,000 individuals in permanent supportive housing now, as well as assisted living facilities and boarding care placements.”
Housing for Health serves people who score very high on a vulnerability index and suffer from co-morbidities often related to chronic homelessness — individuals with serious persistent mental illness, individuals with substance use disorders and those with chronic medical conditions as well. “Our goal is lofty: to end homelessness,” Thomas said. “We demonstrated early on that our program was cost-effective. We were able to reduce utilization of emergency departments and hospitals by housing individuals.”
Star Clinic is small, but it provides high-intensity services. “We have two FTE providers in the clinic and we have an extensive care management team, largely with a goal of stabilizing individuals’ health and that is inclusive of placing people into interim housing or permanent supportive housing,” Thomas said.
She explained her organization’s different levels of integration with LANES. “We have a Smart Alerts list. We're able in real time to get notifications about patients who have outpatient utilization inpatient utilization and ER visits outside of our system. We review that on a weekly to daily basis depending on the number of folks within our clinic who are hospitalized at any given time,” Thomas said. “We review who are highest utilizers across the system. Health plans and our healthcare system are a little bit slow at recognizing high utilization as a referral criteria for ECM [enhanced care management]. It allows us to get ahead of the curve to try to identify people early, and then to actually reach out to them to try to enroll them in ECM. The next thing that we're able to do is provide comprehensive transition-of-care interventions for folks who are hospitalized. It allows us to more comprehensively address critical medical illness that's being addressed outside of our network.”
“We also use LANES as a regular part of our enhanced care management outreach,” Thomas explained. “Folks who are experiencing homelessness are hard to track down. Their phone numbers change all the time. Their physical addresses change from day to day as well. LANES enables us to be able to look up the last utilization, if a person is in the hospital, to be able to contact them when they're in a hospital bed, to make connection, to even visit them while they're there, and then to try to enroll and re-engage with them.”
The work can be very challenging, she said, because the patients have complex end-stage medical diseases complicated by mental illness and substance use. They’re tenuously linked to anyone — social support, family support, caregiver support. “Acute-care utilization is oftentimes correlated with not having routine follow-up and primary care. It is really important for us to be proactive and do outreach,” Thomas said. “The way that our system is oriented in Los Angeles oftentimes leads to silos of care, or patients don't remember where they went, so we're actually able to leverage a platform like LANES to be able to de-silo the care and to follow up related to the care transition, support and care coordination.”
LANES is a start, Thomas stressed, but there are so many more needs. “While we do get a representation of the utilization of our patients, so much of the time, we're still limited in terms of getting fuller medical documentation related to those visits with outside hospitals and systems. We also need a way to robustly coordinate care through this platform,” she said. If care management teams that were involved could have real-time chats and discussions through LANES, it would strengthen the real-time coordination. Real-time notification for a primary care provider about ER and hospital touches is especially critical in the vulnerable population, she added, because it's really important to provide those key time interventions, but also because often, these institutional touches may be the only time when they are able to actually touch base with the patients.