The healthcare landscape is fragmented, with services split among varied payers, providers, populations, and community resources. This silo-ed approach has resulted in redundant services and disjointed care plans. As the nation is moving to a focus on preventative care and treating the whole patient, healthcare organizations are introducing new community care coordination models that aim to improve the experience and outcomes of the patients while managing the overall cost of delivering care. This is especially true for the organizations who are looking to coordinate care for high-risk populations, such as those who have multiple chronic illnesses, struggle with substance use disorder, or are experiencing homelessness.
Common community care coordination models include accountable care organizations (ACO), regional health improvement collaboratives, State and County Medicaid whole person care programs, and other coordinated systems of care. A big challenge these care models face is a lack of data sharing and real-time communication among providers. Most healthcare organizations have an Electronic Health Record (EHR) to collect medical data, but they have no way to share data with other providers, such as social services, substance abuse, etc. Judy Faulkner, CEO of Epic, recently made waves across the healthcare industry with her call for the expansion of the EHR to what she called a “Comprehensive Health Record (CHR).”
Most healthcare organizations have an Electronic Health Record (EHR) to collect medical data, but they have no way to share data with other providers, such as social services or substance abuse treatment programs. Epic’s smartphone-based Share Everywhere solution—which, as Epic vice president of patient engagement Janet Campbell put it, enables patients everywhere “to easily share their health information with anyone they choose, no matter where they are”—encompasses a good idea, but it falls short of the mark of providing a longitudinal picture of patient health.
Apple recently released their Personal Health Records app that allows users to “view medical records easily and securely on [their] iPhone.” Again, the ability to view health information is a great step in the right direction. However, it doesn’t close the gaps in care between health and social service providers. What organizations really need is a Comprehensive Care Plan.
A Comprehensive Care Plan is a living document that is built from customized social and physical health assessments and is accessible to all members of a multi-disciplinary care team. Shared assessments, intake and enrollment, care plans, and progress notes must be accessible at the point of care so providers are fully informed of all aspects of the patient’s condition. For example, data recorded as part of an intake for homelessness would be available to a medical provider treating a chronic condition. The availability of this data can then help the medical provider choose an appropriate treatment plan and tailor it to the unique needs of the patient. Likewise, a community support provider benefits from seeing a patient’s health history prior to recommending a care plan that may be unsuited to the patient.
Uncertainty around healthcare reform and rising healthcare costs will continue to place additional responsibility on providers to be accountable for improving patient outcomes while managing costs. This pressure will most likely accelerate as the Federal Government pushes more responsibility for healthcare down to the States. Providers and communities must continue to implement innovative models of collaboration that connect health and social service providers and enable whole person care coordination. A Comprehensive Care Plan is the key to this collaboration. ClientTrack empowers medical, behavioral health, and social support providers to collaborate on evidence-based, coordinated systems of care to serve high-risk populations.