Community-based organizations perform many services to maintain the health of the people they serve. Only recently have traditional health care providers and payers recognized these non-medical services as a vital component of outcomes-based care — an approach focused on the end results of health care, including fewer hospitalizations, and earlier detection of problems.
One of the most important aspects of outcomes-based health care is care coordination. A patient who receives multiple home and community-based (HCBS) services, and has several doctors and clinics all providing care at the same time is at high risk of getting lost in the system — even with so many people involved. Coordinated care requires extensive data sharing among a patient’s providers, doctors, pharmacists, and labs to be on the same page.
This makes outcomes-based health care tricky. Data gathering and sharing for coordinated care is far from perfected. Primary care physicians, specialists, and pharmacies all collect different data in vastly different ways. Effective care coordination in the future will require identifying which data points represent the “lowest common denominator” to provide value across the continuum of care — so that the people helping the patient to make decisions have the appropriate information.
Obstacles to data and care coordination
Once we achieve effective data sharing, care coordinators must still overcome the issue of limited analytics. Especially in human services, you might obtain data from different providers, claims, labs, and pharmacies, but sifting through that information to find gaps in care can be extremely difficult.1 Care coordinators with social service backgrounds are usually less knowledgeable about health conditions; and when significant events arise, health coordinators rarely understand HCBS services – or how they can impact outcomes.
In addition, data collection is sometimes failing. If providers and claims departments don’t input all the data related to coordinated care, it could appear that there are gaps where no gap actually exists. Sometimes you have to be a detective to find the evidence that care is being provided appropriately for all health concerns.2
Even more prevalent are data silos. It is not uncommon for a provider to have multiple systems to manage different aspects of programs: one system for financials, another for case management, and another for non-medical programs. For payors, it can be even more difficult — one survey of a State Medicaid Program identified over 35 different case management systems in use. This makes it costly, time consuming, or simply impossible to identify common clients across systems or to reasonably analyze the data.
Effective, outcomes-based health care will require changes across the board. Here are some of the key challenges WellSky is focused on:
Uniform data collection. Hospitals, pharmacies, labs, physician offices, HCBS providers and health insurers must be able to share critical data points in a uniform manner — those “lowest common denominators” essential to coordinated care. Leadership is needed to standardize data collection and sharing of those critical data points.
Analytics. Until a method exists to pool data from multiple sources and analyze that data electronically, care coordinators are going to spend vast amounts of time finding the information they need to help their patients.
HCBS technology. The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 funded research that advanced information technology in health care.3 However, HCBS software was largely excluded from these activities. Now it’s time to advance this technology as well.
The Centers for Medicare & Medicaid Services (CMS) established the Testing Experience and Functional Tools (TEFT) Demonstration Pilot to explore some of these issues in the HCBS arena4. TEFT participants developed new technologies with individuals, HCBS providers, and state Medicaid agencies. Two promising initiatives were Personal Health Records (PHR) and Electronic Long Term Services and Supports (eLTSS). PHR was intended to provide Medicaid HCBS beneficiaries access to select information about their programs, case managers, and services. The eLTSS sought to identify, evaluate, and harmonize an eLTSS dataset to improve care coordination.
We are hopeful that the eLTSS initiative can help identify the core data points essential to care coordination. As more providers use applications with standardized data collection and sharing, the easier it will become to share data. However, all of these systems still need improved analytics.
Our goal is that one day, the data collected through Medicare, Medicaid, HCBS services and insurance claims will flow to care coordinators in a format that allows them better monitor patient status, compliance, gaps in care, and potential social and mental health needs.