“The focus is coordination of care.” How Metropolitan Human Services District transformed care coordination for their patients.
November 12, 2025
Introduction
A young male receiving regular treatment for ADHD at Metropolitan Human Services District (MHSD) was admitted to the hospital for a gastrointestinal problem. Nurses at MHSD were made aware of his hospital discharge through PelEX and reached out to his family to schedule a follow-up appointment. The prescriber at MHSD that provides treatment for the patient was prepared with information from PelEX about the hospital visit and was able to ask more questions during their follow-up visit, resulting in a referral to see a gastroenterologist. A medical assistant helped the family schedule the appointment with the specialist and later confirmed with the specialty clinic that the patient kept their appointment.
Organizations like MHSD are using PelEX’s Hospital Utilization Report to be quickly informed of follow-up opportunities, integrate primary care with behavioral health services, provide whole-person care, and ultimately reduce hospital readmissions.
Challenge
MHSD operates community-based programs and services for children and adults with mental health disorders, addictive disorders, and intellectual/developmental disabilities in Orleans, St. Bernard and Plaquemines parishes in Louisiana. MHSD provides psychiatric assessments, addiction treatment, case management, and medication management for persons served. The MHSD care team conducts a comprehensive assessment and addresses the whole person’s health needs by reviewing past clinical encounters and understanding the patient’s treatment history.
“As we engage through conversation with the person served, we are able to glean information that is helpful to resolve the problem at hand as well as optimizing the opportunities to implement the integrated approach to care,” said Debrina Baham, the Registered Nurse Supervisor at MHSD. “This leads to referrals that support all of the needs required by the person served in their road to recovery.”
However, this information is cumbersome to obtain and review, requiring the person served to sign information release forms sent to the physicians and clinics that the patient had seen before, or conducting a chart review. Patients then must wait for MHSD prescribers to receive information, such as medication lists and treatment history, before they can receive all the care they need.
Any delay in information prevents MHSD from capturing and addressing the person’s care needs at the point of care. Without timely and relevant information, MHSD providers miss opportunities to resolve their patients’ needs at the time of their appointment, which may have been difficult to schedule or to arrange transportation. That’s why integrated care approaches – combining behavioral health with primary care – are crucial to ensuring the patient’s needs are met without delay.
Solution
MHSD is a participant of PelEX, a health information exchange focused on making timely, actionable data available to providers to stay up to date about their patients. As a participant, MHSD has access to the Hospital Utilization Report, a daily dashboard report built in partnership with PelEX that provides them with visuals and tables of hospital encounters of their persons served. The Hospital Utilization Report provides only essential information, like name, phone number, encounter details, and diagnoses from the hospital visit, which helps MHSD to reach out to patients discharged from the hospital to plan follow-up care and prepare for the patient’s visit. “Before PelEX, our providers would get ED/IP information months later. Now, the providers are able to discuss all visits with persons served in real-time at the clinic visits,” said Baham. This relieves the burden on the person served to maintain their records and allows MHSD to address all issues at the point of care.
“Before PelEX, our providers would get ED/IP information months later. Now, the providers are able to discuss all visits with persons served in real-time at the clinic visits.”
MHSD asks patients for consent to share their information with the HIE prior to treatment and no psychotherapy notes are shared through HIE. PelEX uses that information to harmonize records about the same patient from outside data sources in a secure database. PelEX marries data from disparate health record sources to ensure the correct patient data is provided to the right organizations within the legal guardrails of Health Insurance Portability and Accountability Act (HIPAA) and Title 42 of the Code of Federal Regulations (CFR). Providers and health care teams can securely access that data through the reports and data feeds that PelEX provides.
Approach/Workflow
In 2024, MHSD initiated an integrated health care pilot to implement a new team that was focused on providing persons provided with behavioral health services assistance to schedule primary care.
- A new team was created, including the Director of Nursing, licensed practical nurses, registered nurses, and medical assistants. Creating a new integrated care team was necessary to dedicate staff to achieve the level of quality demanded by the Certified Community Behavioral Health Center (CCBHC) program.
- The team worked closely with PelEX to understand how to best utilize the tools and adapted their workflows to incorporate PelEX reports into daily routines
- The team pulled a weekly discharge list from the PelEX Hospital Utilization Report to monitor emergency department discharges and coordinate individual follow-up outreach with each person served.
- Providers ask if the person served had seen a physician in the last 12 months and, if the person did not have a physician’s appointment in the last year, they would either be referred to a physician of their choice or to a community healthcare partner of MHSD.
With health information sharing, MHSD providers can obtain information of prior conditions of their persons served, reach out to schedule an appointment, and address prevalent issues during the follow-up visit. MHSD also helps their persons served get to a primary care physician as part of bridging health care between physical and behavioral health. The integrated health team keeps the physicians updated through the patient navigation process and coordinates follow up with persons served to ensure they went to their referral appointment and were able to have their health needs met.
Impact
This integrated health approach allowed MHSD to accomplish the strategic goals of the implementation plan, streamlining internal processes to refer patients to primary care. As of July 2025:
94%
20%
15%
Of persons served were connected to a PCP
Reduction of emergency department visits
Reduction of in-patient hospital readmissions
MHSD’s integrated health team is enabled by PelEX alerts and reports to engage with patients quicker following a hospitalization. The team is also piloting the use of a new PelEX report that captures primary care encounter information for their patients, so they become aware of when their persons served have either received primary care in the past or following a primary care referral. “Our persons served are keeping both appointments with MHSD and the PCP because they are getting calls from our team,” said Baham. “The focus is coordination of care, and we also are able to offer holistic care and help with other needs as well.”
If you are a behavioral health or primary care provider and are interested in learning more about this process, please contact us to learn more and get connected to our participant network.
If you are a patient, ask your provider if they participate in PelEX or contact us to learn more about what we do with the data we receive.
