To provide coordinated care that meets patients’ needs, many networks and communities are developing information systems to share data across clinical and social service settings. In order for these systems to be effective in connecting patients to the right services at the right time, care teams need access to relevant individual-level data that is seamlessly incorporated into their work process.
Data Across Sectors for Health (DASH), a Robert Wood Johnson Foundation funded initiative, was launched to support multi-sector collaborations in sharing data to improve health. Of the ten collaborations that have received support from DASH, five are focusing on improving care coordination between medical and community services through enhanced information sharing that helps orient care around the whole person, not just their healthcare needs. As these collaborations moved from planning to implementation, they generated several lessons related to adapting new workflows based on integrated data and developing end user trainings.
When designing a new care coordination workflow, it is important to answer the following questions:
- Who needs to be part of the process? Who is essential for the process to run correctly? Are there any peripheral people who will be involved occasionally? Are there people who do not need to know how to complete the process, but need to know that it is occurring?
- What information needs to be shared? What data must be shared, and what format does it need to be in? What data would be nice to have, but not essential?
- When does the information need to be shared? When does someone need to receive the data in order to act on it effectively? How often does the data need to be shared?
- How will the information be used? After the information is shared, how will the person use the data to improve care? Are there interventions in place related to the data shared?
Understanding which parts of the current process work well and which aspects create gaps in care, take a long time, or are complicated to perform can help inform the new procedure. Also, to further generate buy-in for a new workflow plan, people currently using the workflow and potential new users should be involved in the conversation to help elucidate the real-life implementation of the process. Having their voices heard and contributing to the design will make them more likely to implement the process as designed.
Depending on the environment, care teams may choose to: 1) design workflows around existing technology capabilities or 2) build new technology to fit new workflow needs. It will be important to determine early on the infrastructure and data required to modify workflows. Four of the five DASH collaborations chose to create new data collection forms for their workflows, while one chose to integrate existing data sources into their system. Some common technical tools that were used to coordinate care included shared plan of care documents, automated alerts and notifications sent across systems, and analytics that draw on multiple types of data to predict risk and identify people in need of more intensive services.
Approaches that Work
Below are five promising approaches taken by DASH collaborations—all of which have unique target populations, goals, partners, and resources, yet are collectively generating lessons with respect to multi-sector data sharing, specifically for care coordination.
1. Understand what end users value and gain their buy-in early on.
Before HealthInfoNet set out to develop a new workflow for integrating social determinant data from Community Action Agencies (CAAs) into their state health information exchange, they documented how the CAAs were already collecting and using data for other purposes as part of their existing workflow. For example, they began by focusing on Head Start data that is already collected during the regular enrollment process and explained the clinical value of this data for at-risk pediatric populations. Taking time to understand the staff’s needs and how the new workflow could add value to their existing data rather being burdensome was key to gaining their buy-in. Read more »
2. Ensure community voices are heard during the process development.
For Altair Accountable Care Organization (ACO), designing a new care coordination workflow began with understanding the personal preferences of the individuals served as well as those of their care team members. To inform the development of an e-Health infrastructure to coordinate mental and behavioral health services for people with intellectual and developmental disabilities, they gathered input from their clients about who should be on the multi-sector support team, what types of behavioral health events care team members should be alerted about, and how they should be guided to act on those events. Read more »
3. Choose a workflow that minimizes extra steps or makes work processes easier.
The Center for Health Care Services, a mental health authority in Bexar County, TX, developed an alert system to notify behavioral health case managers when their clients arrive at emergency departments so that they can intervene earlier and prevent inappropriate hospitalization. By doing so, they automated the manual entry or list management that is often required of their case managers, saving them time to attend to clients. Read more »
4. Communicate roles/responsibilities clearly to all stakeholders.
When the White Earth Nation began implementing WECARE, a care coordination database that screens families on the reservation to a wide range of community services, it was imperative that various tribal programs work in partnership when forming a comprehensive care team around the client’s priorities. Having great educators who could effectively discuss the benefits of WECARE, explain how to implement the screening, and work through any challenges with 800 staff from different community programs has been instrumental in building the momentum needed to implement WECARE reservation-wide. Read more »
5. Test and retest your process and allow for edits by people who complete the workflow.
When the Parkland Center for Clinical Innovation, a part of Parkland Health and Hospital System, began recruiting participants into a program to share patient data between hospitals and food pantries, the health system originally led the recruitment effort. However, social workers found that providers were more focused on treating patients’ clinical needs and were not responsive to food security screenings. Instead, they decided to recruit participants from food pantries where individuals were more comfortable and accustomed to discussing social needs. Read more »
DASH has learned from these grantees how to design new care coordination workflows when leveraging new data sharing technologies. You can find more in-depth descriptions of these projects in our new issue brief, Coordinated Whole-Person Care that Addresses Social Determinants of Health. Additional resources and updates about sharing data across sectors to improve health are available on our website.