Abstracts

Rationale: The goal of this project is to develop and implement a novel patient-centered population health management (PHM) outreach delivery model for chronic epilepsy care in Northeastern Illinois. An independent community-based PHM coordination hub has been established to facilitate access to community resources, telemedicine-linked subspecialty expertise, and 'on-demand' patient-specific education. Such a community-based healthcare management mechanism is necessary to accommodate a markedly increased patient throughput upon implementation of the Affordable Care Act. Moreover, this initiative aims to reduce hospital admissions, while improving the co-morbidity patterns and the healthcare-use behavior of the majority of individuals in the rural under served community with chronic epilepsy and co-morbid psychiatric illness. The clinical implementation of this strategy hinges on the scalability of a networking approach that coordinates near real-time matching of community psychosocial services, and specialized medical needs of individual patients with Rush University Medical Center (RUMC), a tertiary care medical center located about 80 miles away. Bidirectional coordination of video-based telemedicine, and community-based resources includes connection to a local medium-sized medical center emergency department, not affiliated with RUMC.Methods: The methodology combines the following four innovative components: (1) a HIPAA-compliant portable video-conferencing communication protocol and technology for remote access of specialists at a tertiary care medical center with patients and community-based healthcare providers, (2) a custom-designed web-based networking technology employing a relational database for accessing and tracking allocation of all community-based resources, (3) computer-intensive production, archiving and on-demand streaming of an animated education series targeting epilepsy and mental health to accommodate closed virtual classrooms, and (4) an independent community-based PHM coordination hub (O&A) facilitating the above innovative components.Results: Preliminary data demonstrate a 262% increase (489 patients) evaluated since 2010. A four-fold increase is observed in successful epilepsy specialist referrals at the distant tertiary care center (RUMC) of children and adults evaluated in the non-affiliated rural emergency department with a diagnosis of seizures. 'On-demand' community psychosocial resources have been matched with all patients using our networking provider database. Individual-level predictors included insurance status, age, ethnicity, and co-morbidities.Conclusions: This technology-intensive PHM-based outreach delivery model overcomes barriers preventing such coordinated care from being implemented. It significantly expands the geographic reach of a distant tertiary care medical center to an under served region. Preliminary data suggest that an independent community-based coordination hub can efficiently maximize patient access to community resources, medical expertise, and customized patient education.