Programs and Services

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.