September 8, 2026
When gaps in the care transition process limited timely follow-up after emergency department (ED) visits and hospital stays, Erie Family Health Centers sought to improve their patients’ experience by improving continuity of care. Working alongside OCHIN, the health center identified innovative strategies to enhance care coordination and patient engagement, significantly increasing the number of patients who completed a follow-up visit within 30 days after an ED or inpatient discharge.
Watch the video below to learn more about Erie Family Health Centers’ services and how the organization used the OCHIN network to improve care coordination and support better patient outcomes.
In the video, Lee Francis, CEO of Erie Family Health Centers, shares how the organization partnered with OCHIN to strengthen patient engagement, streamline care coordination and help ensure that more patients connect to their care teams during critical moments in their healthcare journey.
Through the wider OCHIN network, Erie also gained access to shared learning opportunities, peer insights and new resources that helped the health center strengthen notification processes, more accurately identify patient risk scores, and develop new approaches to care for patients with complex needs.
As part of this work, Erie established a dedicated Transitions of Care team, standardized transitions-of-care workflows, enhanced data-driven performance tracking, and implemented a new patient tiering model that prioritized support based on individual needs. These efforts created a more coordinated and proactive approach to patient follow-up and care management.
After just nine months, the organization increased the percentage of patients who completed a follow-up visit after discharge from an ED or inpatient setting from 10% to more than 60%.
“One of the things that we’ve been able to leverage by working with OCHIN is to measure our clinical quality, being able to use predictive analytics and then increase our rate of follow-up,” Francis said. “We were able to triple, quadruple that rate within a nine-month time period.”
Erie Family Health Centers’ experience shows how collaboration, data-informed decision making and shared learning can drive meaningful improvements in patient outcomes and experience. By investing in stronger transitions of care, Erie is helping more patients stay connected to the services they need while improving the overall health of their community. Explore more member stories on the OCHIN blog.
