Innovator Awards Winning Team: Northeast Valley Health Center (NEVHC)

Northeast Valley Health Corporation (NEVHC), which provides healthcare to medically underserved residents of Los Angeles County, sought a way to improve the effectiveness of its patient care, with a focus on patients experiencing chronic diseases. To achieve this goal, the organization teamed up with the Los Angeles Network for Enhanced Services (LANES), a nonprofit California Qualified Health Information Organization (QHIO) network. The six-month collaboration resulted in a reduction of unnecessary emergency and inpatient visits for patients with diabetes and asthma.

By embedding real-time patient data into clinical workflows, LANES enabled NEVHC, a Federally Qualified Health Center (FQHC) with 17 locations, to improve care coordination, reduce hospital utilization, and enhance patient outcomes.

Notably, the organizations reduced Emergency Department (ED) visits for the diabetic cohort patients by over 85 percent over six months and hospitalizations by approximately 68 percent. For adult asthma patients, there was a reduction of 82 percent in ED visits and no significant change in hospitalizations.

For these accomplishments, Healthcare Innovation recognized the project as one of its three Innovator Award winners for 2025. Editor Pietje Kobus interviewed several leaders who contributed to this project to gain a full understanding of their accomplishments. NEVHC representatives present in the virtual interview were Christine Park, M.D., M.P.H., CMO; Stephen Gutierrez, CIO; Veronica Ortiz, program coordinator, Quality Improvement; Diego Emestica, M.H.I., program manager II, Chronic Disease; and Jasmine Galindo, M.P.H., director of quality, Health Equity and Innovation. Healthcare Innovation also spoke with LANES CMO Ali S. Zadeh, M.D., M.P.P.

"The credit for this really belongs with the clinic for the most part because they are the ones that do the hard work," Dr. Ali Zadeh admits. "We are the conduit....We have the system where we digest rosters of patients from them....What we do with that is we then take that data and help these clinics use it most effectively to manage that patient population in question. For example, we have weekly meetings with their providers and clinical support teams. We look up charts as needed to assist them and identify which patients require support. We have triage systems within our system that tell us which of the patients that are going to the ED the most out of those rosters and help them identify which ones they need to follow up with."

In short, Dr. Zadeh explains, "We provide the structure, we provide the use case, we provide the weekly meetings, we provide the ideas....Northeast Valley has a team that's calling the patients."

"We decided that we would like to know for certain folks when they entered the ED," Dr. Park answers the question as to what sparked the idea of the initiative. The team decided to focus their efforts on patients with diabetes and asthma—a workflow for care coordinators and health coordinators to reach out to patients prompted by alerts, followed.

LANES joined to analyze whether these notifications and the subsequent workflow were helping to decrease emergency room utilization and hospitalizations.

"We wanted to take advantage of this real-time health information exchange (HIE) to be able to find out that a patient showed up and then maybe wait a day or two to let them get home and recover for a little bit before talking with them and finding out why they had made that decision to go to the ED rather than give us a call to make an appointment," Dr. Park explains.

As far as challenges experienced, Jasmine Galindo mentions the chief complaint patients came in with. For example, a patient with asthma could have visited the ED for an unrelated injury. A situation like this would require more follow-up. Indeed, says Diego Emestica, the more information you have, the more likely you are to connect patients with the right resources. It's even more of a challenge to obtain information on the homeless population who may not have cell phones or an address.

Stephen Gutierrez explains that a method had to be developed at the beginning of the project to identify a list of patients they wanted to track. When any of these patients appeared in the EHR, the system would send an alert. The implementation with LANES was much faster, he says.

Jasmine Galindo, Veronica Ortiz, and Diego Emestica monitor the alerts as they come in, verify the data, and ensure patients are connected to services.

Regarding the internal workflow, Veronica Ortiz notes, "I always go ahead and check whether the patient I received a notification for did go in for an asthmatic symptom. If the patient did go in for asthmatic symptoms and does not have an upcoming appointment, I connect them with our asthma coordinators." If the patient went to the ED for asthmatic symptoms, follow-up will be needed to prevent them from having to go to the ED again.

Emestica says the ancillary service staff's feedback from patients is very positive. "The more that we see the patients that we know, and hopefully see them thrive, the better that is for us as healthcare providers," Dr. Park adds.

Looking into the future, Dr. Park says they have added another cohort of patients. These are people who visit the ED multiple times. "The care team reaches out to the patients to try to see if the patient is doing OK and to schedule an appointment in primary care after that ED visit or inpatient admission....Our hypothesis is that the number will go down after our intervention." The other cohort is the enhanced care management enrolled members, Dr. Park explains. "Enhanced care management is a California medical version of Medicaid." Lead care managers are assigned to these patients who enroll in this program based on eligibility definitions such as homelessness, substance use disorders, and mental illnesses.

When it comes to advice for healthcare leaders who want to implement a similar program, Galindo advises taking the leap. She says to analyze where you are and go from there to see how improvements can be made. Ortiz agrees, "Go for it. At the end of the day, we want to ensure that our patients are being well taken care of and they're well managed regarding their chronic diseases." Going in with empathy is essential, Emestica adds. "We want to customize the approach..instead of trying to fit patients in a one-size-fits-all." Starting with smaller cohorts is the best way to go, Galindo mentions because that allows for determining what works and what doesn't.