For many rural-based patients, care coordination is a challenge borne out of social determinants more than anything else. It’s lack of transportation, limited food and pharmacy options, reduced funds for medication, and low health literacy.
The UnityPoint Health system, headquartered in Des Moines with hospitals across three states in the Midwest, cares for countless patients that face such challenges. Within its Medicare Pioneer accountable care organization (ACO), the UnityPoint Health ACO, which covers patients across eight counties within the state, the scope of these issues go even deeper.
“We are challenged not just by income— the household income in our communities is lower than the state average – but our proportion of elderly residents is greater than the state average. Our Medicaid health status is more challenged than other counties. We have a perfect storm in the [Medicare] Pioneer counties,” explains Pamela Halvorson, regional vice president of clinic operations at UnityPoint Health.
As a result of this “perfect storm,” many patients in the region fail to receive vital public health services. In 2013, Webster County—one of the eight covered by the ACO—ranked 87th out of 99 in terms of health outcomes among Iowa counties, according to http://www.countyhealthrankings.org, a Robert Wood Johnson Foundation program. “We needed to have a model that could be consistently deployed across more than just one community and would address all of these variables,” says Halvorson.
That’s where the Tri-Navigational System, an initiative of improve care coordination between disparate care providers, entered the picture. Thanks to becoming a Medicare Pioneer and a grant from the State of Iowa, UnityPoint and Webster County Health Department found themselves deeply connected in trying to improve care coordination within the region. During those conversations, the two sides came up with a system to connect primary care and mental health providers with public health officials, by instituting care navigators and integrated technology spread across the enterprise.
“We were able to grow up together in this care coordination environment,” says Halvorson of UnityPoint and the Webster County Health Department.
How Tri-Navigation Works
The idea behind Tri-Navigation is to make a complex care system for patients with complex issues more unified and simple. Patients are introduced to the Tri-Navigational System based off a provider’s referral. The system uses three navigators— one each in mental health, primary care, and public health. The navigators discuss on a weekly basis the patient’s challenges and how they can get various services to care.
“We do a social intake on the referral and we communicate what we find back to the physician, emergency room, or primary care physician, so they know what’s happening in the community to help them on the medical side,” says Kari Prescott, Executive Director at Webster County Health Department, about the public health side of the system.
With the three navigators talking to each other on a constant basis, Halvorson says the “total patient story” is known. They also keep it simpler for the patient and only one usually is contact with them.
It also helps the system can rely on an integrated electronic health record (EHR) system from Epic Systems (Verona, Wisc.) to connect the mental health and primary care sides. The public health side is brought into through Champ Software’s (North Mankato, Minn.) Nightingale product, a web-based software that allows the providers to track and monitor social determinants. However, that side isn’t completely interoperable with the Epic EHR.
“We have workarounds to exchange [public and primary care information] but it’s not a seamless, interoperable environment,” says Troy Martens, COO at UnityPoint Health’s Trinity Regional Medical Center. “Our goal is to be able to query and exchange on-demand those key clinical data elements between our EHR environment and the public health EHR environment.”
On top of bringing together the two sides from a vendor perspective, Martens says they are submitting a grant released by the federal grant that’s designed to target and improve the overall interoperability between non meaningful-use providers.
Successes and Next Steps
The current challenges go beyond complex technical difficulties. The fact is, Halvorson says, the region and its citizens are connecting with rudimentary digital tools over rudimentary digital highways. She says until recently, people in the area didn’t have capability or desire to use smartphones. “Just thinking about how basic information flows to and from patients is a real challenge,” says Halvorson.
While the work is ongoing, the fact they can connect disparate public, primary, and mental health care providers at all is an accomplishment in itself, given the challenges others have faced across the country. Moreover, the Tri-Navigational System has already shown to be a statistical success. In the first six months of 2014, 2,189 patients identified a social determinant as a barrier to care. Of those 2,189, 1,233 patients received coordinated direct service and 1,096 received coordinated social assistance.
In total, more than 3,000 patients across six of the eight counties received services since the beginning of the program in 2014 until April of this year. Prescott notes those six counties had already formed an agreement and they are working on bringing in the other two counties covered in the ACO into the fold.
That’s part of the next steps the Tri-Navigational team is planning on taking. Prescott says she’d like to standardize the way public health workers communicate with patients and providers and utilize those IT tools. Also, Halvorson says she’d like to see advanced risk stratification models put into the EHRs to find the unidentified needs of patients before they enter the system.
“That’s my dream. Identifying all of our severely and mentally ill patients and getting them enrolled in our integrated health home that’s designed to meet their needs. So we’re not looking for them or they had a crisis somewhere before we had them aligned to the medical home,” Halvorson says.
