Medical Home Network, a third-party facilitator of collaborative care on Chicago's south side, says members of its network have reduced 30-day readmissions by 25 percent, increased timely post-discharge follow-ups by as much as 130 percent, and also reduced overall cost of care since December 2012.

Network executives say a key factor in the improvement has been a new care coordination platform called MHNConnect, a web-based portal which provides real-time alerts to primary care providers whenever patients utilize inpatient or emergency hospital services across the Medical Home Network community.

According to a recently conducted review, the number of Medicaid patients who visited their assigned primary care physician at MHN member Esperanza Health Centers within seven days after being discharged from the hospital or emergency department increased from a 25.3 percent pre-implementation baseline to as high as 58.3 percent in certain months; and Esperanza's first intervention year follow-up rate averaged 47.2 percent.

The monthly high of 58.3 percent represents a 130.4 percent increase over the pre-implementation baseline. In addition, hospital readmissions within 30 days of patient discharge decreased from 11.2 percent to 8.4 percent post-intervention, a 25 percent reduction in readmissions.

Esperanza quality improvement nurse Carmen Vergara said the key to Esperanza's success has been the connectivity of MHNConnect anchored by a trained workforce of care coordinators.

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