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Transcript of Care Exchange
No plan for follow-up Homeless back on the streets Medical and care systems don't talk to one another
2-3 mos for SF to discover bursts of ER over-utilization Need:
Primary Care Coordinator & Real-Time Intervention CareLink.me Emergency Care Family/Friends Mental Health Care Primary Care Coordinator Mobile care plan
Geo-location event logging Social Services 5% patients = 50% health care costs Hillary Lin, Stanford MD
Nathan Schuett, Stanford developer
Zak Zibrat, EMT, Berkeley
Jackie Lee, MIT, Rock Health developer
Jack Chi, Health IT developer
JR Fieser, MD Physician
Ronaldo Barbachano, Code For America CareLink.me >90% homeless have smartphones in SF: Lifeline Project by US gov't ID Patient Primary Care Coordinator Food
Social Geo-Location Services Service Map Food, shelter, services Geo-Location Event Logging ER visits
Other provider encounters Our Team Care Plan Homeless, using Urgent/Emergent care ID and Contacts Care Plan