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Care coordination is one of the principle “change concepts” of the Patient-Centered Medical Home process and presents opportunities that reduce barriers to care. Practices that are effective at care coordination are able to effectively build “community-clinical linkages,” which are collaborations between health care practitioners in clinical settings and programs based in the community—both working to improve the health of people and the communities in which they live.
Developing strong community-clinical linkages connects health care providers and community-based organizations, as well as organizations like public health agencies, housing authorities, transportation services and more, so they can collectively improve access to preventive and chronic care services as well as services that address the social determinants of health (e.g. affordable housing). Building such linkages is critical for improving overall population health.
To help facilitate this work, within the last several years an increasing array of new technology platforms have emerged with the shared aim of enabling health care organizations more easily identify (screen) and direct (refer) patients to community-based organizations. These platforms offer varying degrees of services and features and levels of integration within the patient record. However, whichever platform a community chooses to adopt, it must serve and perfectly overlay the care pathways the community deems important; the technology must be in service to existing patient needs at the local level rather than being a solution looking for a problem.
At the Leadership Council meeting on April 15, we will explore digital clinical-community linkages. Michael Arnis and Chase Napier from Health Care Authority will describe the elements of electronic community information exchanges (CIEs) and HCA’s vision for CIEs in the future. We will also hear from staff from Elevate Health, the ACH serving Pierce County, who will discuss their real-world experience with implementing a sophisticated CIE. And we will have the opportunity to hear from you regarding your thoughts around this technology and how it can link-in community-based organizations.
Please plan on joining us.