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Utilizing Actionable Data Analytics to Support Patient Navigation Enrollment and Retention Within Federally Qualified Health Centers

The GNOPQii pilot partnered with eleven (11) Federally Qualified Health Centers throughout the Greater New Orleans Metro area to implement the pilot. The goal of the project was to explore if offering high level patient navigation coupled with actionable visit data could have a direct impact on the divergence of patients identified as frequent users of local Emergency Departments for the purpose of primary care visits and direct those patients to establish primary care homes with one of the eleven partnering health centers. The patient navigation services were provided by Catholic Charities of Greater New Orleans. Each of the partnering health centers were able to refer patients into the program whom they identified as frequent users of the ED for non-emergent visit, who could benefit from patient navigation services and support services to reduce barriers to the patients receiving primary care in the health center. A total of 337 referrals were made and 145 patients were enrolled into the GNOPQii pilot program. Participants were between 19 and 64 years old (M = 40.2 years), at or below 100% of the FPL, and who otherwise had no medical insurance at time of enrollment. The majority of enrollees were female and black or African American; 93.2% had at least 1 encounter at a hospital or clinic that is connected to the GNOHIE (Greater New Orleans Health Information Exchange), and of those, more than 90% had at least 1 clinical encounter. According to PN care plan documentation, the direct services needed the most by patients were transportation and medication resources.

This project aligned perfectly with the mission of LPHI; the program focused on improving access to primary health care, using technology to aid in the improvement of health outcomes and building partnerships to accomplish the goals. The project also was a demonstration of the benefits of leveraging resources and partnerships to aid in the quality improvement efforts for the clinical partners as it relates to population health in the primary care setting and a demonstration of how the efforts of the project can result in cost savings.

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