Cena Health
Cena Health

Program Reference

Population & Eligibility

Clinical Criteria

  • HbA1c ≥ 7.5% (lab within 90 days)
  • Type 2 Diabetes diagnosis (ICD-10: E11.x)
  • BMI ≥ 25.0
  • At least one SDoH risk factor (Z codes)
  • English or Spanish speaking

Target Demographics

Adults 18–75 residing in LA County. Program prioritizes underserved communities with food insecurity, housing instability, or limited transportation access. Bilingual (English/Spanish) care coordination available for all patients.

Referral Pathways

  1. Primary care physician referral via Epic (auto-sync)
  2. Endocrinology referral with lab confirmation
  3. Community health worker outreach (walk-in eligible)
  4. Emergency department follow-up protocol

Tracked SDoH Codes

Code Label Description
Z59.1 Housing Instability Inadequate housing, frequent moves, or unstable living situation
Z59.4 Food Insecurity Lack of consistent access to adequate nutrition
Z60.2 Social Isolation Lives alone with limited social contact or support network
Z59.0 Homelessness No fixed address or residing in temporary shelter
Z56.0 Unemployment Currently unemployed and seeking work

Services

Clinical Services

ServiceFrequencyBilling CodeNotes
RDN Visit Monthly (first 3 months), then quarterly 97802, 97803 45–60 min initial, 30 min follow-up
BHN Session As needed, min quarterly 90837, 90834 Triggered by HADS score ≥ 8
Lab Draw Quarterly (HbA1c, lipid panel) 83036, 80061 Quest Diagnostics preferred
Care Coordinator Check-in Bi-weekly — Phone or in-person, no billing code

Food Delivery Schedule

  • Frequency: Weekly (7 meals per delivery)
  • Meal types: Hot meals (default), cold meals on request
  • Order change cutoff: Wednesday 11:59 PM for following week
  • Missed delivery protocol: Automatic alert + reschedule within 48 hours

Kitchen Partners

Fresh Bites Delivery Co.
(213) 555-0101
East LA, Boyle Heights
Nourish LA Kitchen
(310) 555-0188
South LA, Inglewood
Community Cooks Collective
(323) 555-0212
Mid-City, Koreatown

Measurement Priorities

Key Clinical Targets

HbA1c goal < 8.0%
BP target < 140/90 mmHg
Weight change (6 months) ≥ 5% reduction
Dietary diversity score ≥ 6 (0–9 scale)

Operational Tracking

Meal adherence ≥ 80% accepted
Session attendance ≥ 75% visits kept
Alert resolution SLA High ≤ 24h · Medium ≤ 72h
Quarterly reports due: March 31 · June 30 · September 30 · December 31

Integration & Access

EHR Integration

Epic connection Connected
Last sync Today at 6:14 AM
Data TypeRecords Synced
SDoH codes 147
Lab results 891
Vital signs 2,304

Alert Resolution Metrics

Period:
Category Avg Hrs to Resolve Outstanding Resolved This Month
Clinical 18.4h 5 12
Social 31.2h
4 8
Delivery 6.8h 2 22
Safety 4.1h 1 3

Target SLA: High severity ≤ 24h · Medium severity ≤ 72h

Outstanding vs. Resolved (this month)
12 outstanding · 45 resolved
Patients with current HbA1c on file
78% (39/50 patients)

Team & Access

Cena Health Team Contacts

Name Role Email Phone
Dr. Sarah Chen RDN Lead s.chen@cenahealth.com (310) 555-0158
Marcus Webb BHN Lead m.webb@cenahealth.com (310) 555-0782
Maria Santos Care Coordinator Lead m.santos@cenahealth.com (310) 555-0110

Partner Access Levels

Partner Access Level Data Visible
Fresh Bites Delivery Co. Delivery Only Delivery schedule, address
Nourish LA Kitchen Delivery Only Delivery schedule, address
Community Cooks Collective Delivery Only Delivery schedule, address