In 2004, the IHN began to establish workgroups to plan for increased coordination and integration of safety net services. Since then, the CRC program, NCAP partnership, ETO service line, and TOC task force have been established.
The Community Referral Coordinator (CRC) Program utilizes Referral Coordinators to connect patients in the inpatient units or emergency departments of hospitals with a primary care provider for follow-up and preventative care. The program focuses on serving medicaid and uninsured patients; however, works with all patients in need of a medical home. The program begain in June 2007 and currently serves patients of BJC Barnes-Jewish Hospitals, SSM St. Mary's Health Center, Saint Louis University Hospital, SSM DePaul Health Center, Mercy Hospital St. Louis, and Phelps County Regional Medical Center. The Referral Coordinators are employees of the IHN who work on-site in the hospital emergency departments and inpatient units. The program goals are to; enhance access to a primary care home and health resources for all patients regardless of ability to pay, reduce non-emergent use of emergency departments and low acuity re-admissions, enhance continuity of care, and strengthen communications/processes among safety net providers.
The Network Community Academic Partnership (NCAP) works to connect health care centers and organizations with academic institutions, fostering increased communication and collaboration between safety-net health providers and researchers on the basis of working towards a common goal; affordable, accessible, quality healthcare through comprehensive patient-centered collaboration. Opportunities for partnership between IHN community health centers and academic insitutions are increasing as funding prospects require demonstrated collaboration with existing networks of community partners. These partnerships have the potential to encourage and evidence-based, regional approach to local health care delivery.
The IHN provides an outcomes management service that utilizes the Efforts to Outcomes (ETO) software as a tool to assist health centers, hospitals, and organizations. ETO is a metrics driven platform designed to provide quality indicators and performance meansurements, as well as initiate quality improvement efforts. The ETO software is customizable to manage data in order to track effectiveness and improve outcomes for clients.
The Transitions of Care (TOC) Task Force is a collaborative oversight group of the CRC program. TOC is cross functional, facilitating communication between providers, patients, and healthcare facilities, with a goal of fostering effective transitions of care for patients. The main goal of the task force is to promote and sustain efficient patient transitions between hospital (inpatient or emergency department) and the outpatient setting (primary care or urgently-needed specialty care) through improved communication and coordination across health care organizations and with patients.
The purpose of Re-entry Community Linkages (RE-LINK) Program is to improve the health outcomes for minority reentrants in transition from jail to their communities utilizing collaborative community efforts through a health and social services network comprised of physical health, behavioral health, and social support services. The goals are (1) To improve collaboration and coordination among criminal justice, public health, social service, and private entities (2) Reduce health disparities experienced by the reentry and justice-involved population, (3) Increase access to needed public health, behavioral health, health care coverage, and social services, and (4) Reduced recidivism.
Funded as part of Missouri Foundation for Health’s Infant Mortality Reduction Initiative, IHN is the lead applicant partnering with Affinia Healthcare, Family Care Health Centers, St. Mary’s/SSM/St. Louis University, Barnes Jewish/BJC/Washington University, St. Louis Regional Health Commission, GenerateHealth, St. Louis University’s College for Public Health and Social Justice, Queen of Peace, Good Shephard Children, Family Services/Mercy and Community Birth & Wellness Center, and former Centering Pregnancy mothers to pilot and implement, “Enhanced Centering Pregnancy” over a two-year period. The primary goal is to combat trauma and toxic stress at a system level integrating behavioral and medical services to improve the outcomes for pregnant woman in the St. Louis region. The main objectives are to (1) Increase trauma awareness and promote trauma-informed practices in perinatal teams within the participating organizations; (2) Enhance the Centering Pregnancy curriculum via patient experience and medical and behavioral health expertise to include a stronger focus on stress, trauma, and resilience; (3) Identify capacities and barriers to behavioral health assessment, referral, and treatment for centering patients, and as possible, provide improved screening, response, and referral to Centering patients.