A More Complete View to Drive Better Outcomes
InterCommunity Health Network Coordinated Care Organization (IHN-CCO), part of Samaritan Health Plans, is one of 15 coordinated care organizations in Oregon tasked with delivering managed care to the state’s Medicaid recipients. With a focus on prevention and management of chronic conditions, each CCO is a network of physical, behavioral, and mental health providers. The state’s mandate for these organizations is to improve care by integrating behavioral, mental, and physical health; shifting from a fee-for-service to a fee-for-value payment model; focusing on social determinants of health; and decreasing medical costs.
Linking Patients with Providers
Serving Benton, Lincoln, and Linn counties, IHN-CCO set out to meet the state mandates by asking stakeholders for input. The response was that the providers in the network wanted more transparency into their patient’s healthcare data. Providers and caregivers said they didn’t know what happened to patients after and between visits. They worried that the gap in access to information could lead to a gap in care.
Data Transparency Across the Community
IHN-CCO selected InterSystems HealthShare® as its connected-care platform to provide information transparency to all community participants.
“We created data connections so that during a visit, physicians viewing the community record could see services received by patients from other providers,” says Michelle Crawford, Director of Data Strategy and Operations, Samaritan Health Plans. “They can also access historical encounters attributed to a specific provider.”
IHN-CCO prioritized the order in which it would create connections by looking at member demographics. It targeted five area hospitals and then the clinics with the highest patient volumes.
It then focused its efforts on behavioral health providers. There were a number of barriers to connecting these providers, including privacy and security concerns and technical challenges. However, one county implemented an electronic medical record (EMR) platform that included behavioral health providers, and subsequent instances of connecting with the same system become much easier.
Since dental providers are an important aspect of healthcare, IHN-CCO started integration projects with all dental plan organizations across the state.
IHN-CCO also integrated with The Sequoia Project/eHealth Exchange and the Department of Veterans Affairs. Since some local providers cannot connect to IHN-CCO, they will use nationwide networks like these to access health data.
Realizing the Benefits of Data
IHN-CCO and its stakeholders are realizing the benefit of having comprehensive, aggregated health data to support programs such as the Centers for Medicare & Medicaid Services Merit-Based Incentive Payment Systems, Quality Measure, and Alternative Payment Methodologies reporting, all of which require detailed and comprehensive health information. Providers need data and help with measuring quality outcomes as they shift to the new fee-for-value payment model; now they have data in one place.
IHN-CCO has so far aggregated to the data from approximately 56,000 members, enough that providers have the foundational information needed to treat patients at the point of care.
The next challenge and opportunity is building the analytics tables and validating the data for key stakeholders. Many large healthcare delivery systems using market-leading EMRs are aggregating clinical data from hospitals and provider practices. IHN-CCO wants to build an overall unified community health record including not only medical information, but also social determinants of health, defined by the World Health Organization as, “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life1.”
IHN-CCO believes the more providers know about their patients both clinically and nonclinically, the better they will be at treating the whole person. One of the obvious challenges is access to social determinants of health data in a shareable, structured electronic format that allows for closed-loop referrals. The CCO is working with community organizations to create a form for input of this data, since most of it is not in electronic format.
Using both clinical and social determinants of health data will help providers identify high-risk patients, focus more on their care, even view them differently. For example, say a patient misses a few visits with a primary care doctor. In Medicaid terms, the patient is “noncompliant,” which implies willful negligence of rules. Ultimately, IHN-CCO wants its providers to shift from thinking that such a member is “noncompliant” to instead realizing that he or she perhaps can’t be compliant because of homelessness, lack of transportation, or inadequate access to food.
“It makes sense for us to bring social determinants of health information to physicians and the care team, particularly given the immense potential effect social determinants of health have on our healthcare outcomes” adds Kim Whitley, VP Chief Operating Officer, Samaritan Health Services. “HealthShare enables us to look at the patient more holistically and coordinate care more effectively.”
1 – http://www.who.int/social_determinants/en/