For many individuals, particularly those who face significant challenges, fragmented care is a critical barrier to achieving positive outcomes. Necessary services are often split between healthcare and social services and are then broken down even further by medical specialties, social service needs, and even payer regulations. In order to access care, patients must find a way to first locate and then coordinate with each of the different providers or organizations that address their specific challenges. Care coordinators can help greatly in this process, but it is not uncommon for individuals to be assigned to multiple care coordinators by different service silos. This fragmentation of care is time-consuming, complicated, and often leads to patients either missing out on critical resources or receiving incorrect care because care plans were developed without providers having access to the whole picture. Thankfully, this fragmented approach is starting to change.
In past articles, we have highlighted many different community care coordination models that are being implemented around the country. These include Health Neighborhoods, Whole Person Care Medicaid Waiver pilots, Delivery System Reform Innovation Projects (DSRIP), Community Health Information Exchanges, and so forth. Though they vary in structure and methods, the common goal of each of these networks of community and health providers is to improve outcomes and reduce the cost of care for vulnerable and high-risk individuals. In order to accomplish this common mission, each program must have a way to connect individuals with the applicable resource, develop an appropriate care plan, track accountability and performance, and follow up with individuals and providers.
“No Wrong Door”
When addressing the needs of high-risk individuals, the first barrier to overcome is getting them access to all needed resources. It is not uncommon for an individual who is trying to access one type of service to also be in need of additional resources. When various health and human services operate within individual silos, it creates a barrier to accessing care. However, if a network of health and community providers is operating a “no wrong door” policy it allows individuals to be able to apply for one type of resources and be assessed for any number of other needs. For example, someone applying for housing support may be identified as also benefiting from employment services. When providers are able to refer clients to resources outside of their expertise, it simplifies the process of connecting individuals with each of the services they require and reduces the chances of them missing out on addressing critical needs.
“Closing the Loop”
Of course, creating a referral is only half the process. It is equally important to have a way to ensure that the referred services were completed, which is also known as “closing the loop.” Historically, closing the loop on referrals to other providers or community organizations has been a time consuming and often unsuccessful process due to lack of communication and visibility between organizations. In order to successfully close the loop on referrals, care coordinators from all participating agencies must be able to track referral activity from the time a referral is made until the ultimate outcome.
Comprehensive Care Plans
The collaborative tools needed for closed loop referrals are also necessary for creating and managing 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. The availability of this data can then help the care coordinator match community resources with the client’s needs, such as languages spoken, hours of operation, and geographic proximity.
Let’s imagine a community health worker has just been assigned a new client. Juan Garcia has recently been released from prison and is homeless, unemployed, and struggles with substance use. In order to help Juan overcome his challenges, his community health worker must be able to provide informal counseling, health screenings, and closed loop referrals.
To do this, the community health worker uses a care coordination platform to create and manage a Comprehensive Care Plan for Juan to address his medical and health-related social needs. This plan gives Juan the care and services he needs to successfully reintegrate into the community. Using the tools available on the care coordination platform, Juan’s community health worker is able to track his progress from initial intake through each step of his individual care plan and track referrals to completion.
“No wrong door” policies, closed loop referrals, and comprehensive care plans are all critical pieces of providing high-risk individuals truly effective whole person care. Eccovia Solutions is proud to partner with our clients to develop a closed-loop referral approach that improves care coordination by helping community health workers properly match community resources with a client’s needs, and then helping them follow through until care completion with closed-loop referrals.
Learn more about Los Angeles Housing for Health has used our ClientTrack Community Care Coordination Platform to improve care and reduce ER visits for individuals experiencing homelessness in Los Angeles County.