Care Coordination Strategies

Electronic Health Record (EHR) system use has been increasing across the U.S. at a steady pace for the past five years, setting the stage for interoperability, which allows these systems to communicate important health data about patients from provider to provider. While these systems and their ability to exchange information are not perfect, this rapid integration of new technology is an important step for better care coordination—reducing errors and bridging the gap through continuity of patient care.  Altarum has a history of developing information technology solutions that address these issues by storing and providing access to information that can be accessed by multiple providers in different settings, like the Michigan Care Improvement Registry.

The Care Coordination Strategies concept links existing technology to a patient’s care provider team, regardless of health network or specialty. The health care staff would then have an alert mechanism when a patient’s status changes, enhanced provider-to-provider communication through secure sharing of patient information, and a referral pathway where they did not previously exist.

A recent proposal suggests that the future of information technology (IT) in care coordination exists in four categories.

  • Identify collaborators: identify all members of a patient’s care team across all settings;
  • Contact collaborators: use IT tools to facilitate both urgent and routine communication between care team members, including electronic referrals;
  • Collaborate: structured clinical communication through sharing of the patient’s care plan and Wiki-like collaboration on formulation of treatment plans; and
  • Monitor: prevent care teams from ‘dropping the baton’ by using tools that generate alerts with patients is not on their treatment plan or misses an important follow-up.

However, successful care coordination goes beyond just innovative IT solutions. Care Coordination Strategies involve engaging patients and care providers using traditional and nontraditional communication methods along with health IT to thread the needle, so to speak, to ensure patients are following the care plan and the care team is informed. For example, we can reduce preventable disease by identifying the most vulnerable populations and educate them about preventive care, build information architecture between providers for a better referral pathway and data exchange, and create an analytics tool to monitor care continuity and impact.

Our latest project, The Michigan Caries Prevention Program, is a prime example of this innovation. It is a three-year project funded through The Center for Medicare & Medicaid Innovation, which focuses on reducing childhood dental disease in Michigan’s children covered by Medicaid through these primary objectives:

  • Creating a closed-loop referral tool between dentists and physicians, utilizing existing state infrastructure, and developing information architecture to support the data flow;
  • Engage 1,500 primary care physicians to integrate preventive oral health services into well-child visits to improve caries rates, encourage dental referrals, and educate Medicaid recipients on services available;
  • Provide access to preventive oral health services in communities without appropriate provider capacity through provider training;
  • Monitor the efficacy of the program statewide; and
  • Empower parents to take an active role in their children’s oral health.

By utilizing existing technology, engaging all parties involved, and ensuring access to the resources available, improved care coordination will increase the proportion of children seeing the dentist by age one and reduce costly tooth-related emergencies. Overall, the goal of this program is to establish the technology infrastructure needed for value-based care and quality improvement for children's oral health in Michigan.