Integrating data from sectors such as medical, behavioral, and social services enables care teams to proactively identify and address the needs of patients—improving outcomes for individuals while having positive community-wide health and cost implications.
The latest webinar in the All In project showcase series featured presentations from projects in two communities developing technology solutions to improve care coordination for special needs populations. In case you missed it, below is a recap of their projects and key takeaways.
Community Project #1: Children’s Comprehensive Care Clinic
Children’s Comprehensive Care Clinic in Austin, Texas is designing a patient-controlled technology platform to integrate care for children with complex chronic conditions across different members of the care team including physical, mental, and behavioral health providers, habilitation providers, educators, and family members. Data is collected from schools, electronic medical records, payers, health information exchanges (HIEs), and the patient and displayed in a mobile application. The parent or guardian grants access to their child’s information to different members of the care team. Currently in the prototype phase, the clinic intends to develop modules for durable medical equipment and home health therapy information and pilot the application on 200 patients within the next 3 months.
Community Project #2: Altair Accountable Care Organization
Altair, an accountable care organization led by Lutheran Social Service of Minnesota, is integrating behavioral health data into Simply Connect, an HIE. Altair and a group of physical and behavioral health providers will use this data to coordinate care across the team and ensure appropriate services are provided for people with intellectual and developmental disabilities. Additionally, a platform will be built for the behavioral health providers to access their patient’s information stored in the HIE. The system will enable members of the care team to communicate more effectively and send alerts when important health events occur so that the team can respond appropriately.
Key Takeaways
Develop a clear understanding of the barriers to services and how they arise
Understanding and acknowledging the greatest barriers and gaps in care upfront helped both project teams develop effective solutions to address these issues.
At Children’s Comprehensive Care Clinic, stakeholders identified barriers to care coordination through personal experiences and four all-day group discussion sessions. Previous care coordination attempts had proved expensive and inefficient because they required additional staff positions and created duplicative work for providers at different entities. Contributing to this problem was their siloed data and technology systems, which positioned patients as passive recipients of care when in reality, the patient and their families were typically the people who held the most knowledge about the patient’s well-being. Collecting this information helped them design a more effective, patient-centered system.
Altair and Simply Connect also recognized that often a patient’s care team operates in silos with partial information. They found that important communications between service providers did not always occur or had significant lag time, resulting in inadequate support or care for the patient. Additionally, they found that care team roles were not always clearly delineated, resulting in inconsistent or insufficient information sharing. For example, 60% of Altair’s members have a primary diagnosis of an intellectual or developmental disability with a secondary diagnosis of a mental or behavioral disorder, but the majority of the time, the secondary diagnosis was not being shared at the time of intake and if the secondary diagnosis developed during their hospital stay, it was not always shared with all members of the care team. Understanding these issues helped them develop a better process to alert members of the care team of relevant information that would improve patients’ care.
Design technology solutions around workflows that remove gaps in care
Both projects worked to ensure that each member of a care team had access to relevant individual-level data that was seamlessly incorporated into their work process so that they could remove barriers to providing effective care.
The Children’s Comprehensive Care Clinic designed a solution to address their identified issues. They quickly realized the importance of shifting towards a care integration approach that ensured the patient was at the center of their model. They designed a mobile application using human-centered design principles so that data was integrated and displayed in an easy-to-read format, which helped reduce duplicative work and gaps in care. Additionally, the patient or their parent controlled who had access to information, minimizing privacy concerns and relegating them as an active participant of the care team.
Simply Connect collects and stores information on who is on a patient’s care team and their role on the team. They pull in mental and behavioral health assessments from all members of the care team so that even if the patient does not disclose their secondary diagnosis, the provider will still have that information in their medical record. Furthermore, if a patient is newly diagnosed or is at high risk for an event, an alert goes out to every member of the care team so they can adjust the level of support given to the patient.
Demonstrate the value for each specific stakeholder
Children’s Comprehensive Clinic engaged family members and the extended care team in day-long sessions to provide feedback that would help inform the design of the application. This approach allowed stakeholders to feel involved in the process and have confidence that the end product would meet their needs.
Simply Connect also took the approach of demonstrating the impact their solution would have for each stakeholder group. They sent communications educating the stakeholders on why their involvement was essential and what benefits the stakeholders would receive in return in order to get their buy-in. They presented how their technology solutions would add value by increasing access to more comprehensive information and support systems, filling gaps in care, and improving health outcomes.
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