With a State Innovation Model (SIM) grant, the Greater Flint Health Coalition in Flint, Mich., has worked to better meet the needs of people who were showing up regularly in the city’s hospital emergency rooms. Great Lakes Health Connect, a health information exchange, helped the coalition deploy a closed-loop referral software system to connect healthcare providers and social service agencies.
The SIM effort has led to a 15 percent reduction, since Nov. 2017, in emergency department utilization by the target population. In an interview, Great Lakes Health Connect CEO Doug Dietzman said his organization partnered with the coalition to help identify who “super-utilizers” of the emergency department were, since it had data from the three main hospitals. “More importantly, once they were identified, we had to coordinate how transitions of care would take place from the provider to a community hub that was created for SIM, then down through specialty hubs dealing with either substance use issues, behavioral health issues, or other social needs folks had related to water, transportation or other things,” he explained. Great Lakes Health Connect worked with the coalition to build the coordination platform using CollaborNet Referrals from Atlanta-based startup Holon Solutions. “So we are doing end-to-end, closed-loop communication and management of those transitions for all those patients in Flint,” he added.
Dietzman stressed that working on referrals is less about making it electronic and more about figuring out work flows. “You could use Direct or secure e-mail,” he said, “but we wanted to solve the work flow problem, which is how does an organization make sure they get all the information they need that is legible the first time so they can work with the client, and on the sending side, how do I know whether they got the information or what happened to the client? We were trying to link that work flow to make sure both sides got everything they needed, and we actually facilitated the conversation rather than just sending an electronic document somewhere.”
The 15 percent reduction in ED visits by the target population isn’t all attributable to the improved referral process and technology solution, Dietzman added. There was a lot of hard work by case managers and clinicians to make it happen. “But certainly the ability to collaborate and close the loop to make sure people got served was a piece of that puzzle in which they saw the significant improvements that the state was looking for.”
Following the early successful deployment in Flint, the HIE rolled out the Holon referral platform statewide, and has topped 1 million closed-loop patient referrals using Holon’s referral application.
It will deploy Holon’s full application suite statewide later this year, saying it would enable 129 Michigan hospitals and 4,000 provider organizations to surface relevant insights, such as care gaps, within the EHR workflow. Holon describes its solution this way: It uses patented sensor technology to work in the background to monitor data from third-party analytics platforms, portals, outside providers’ EHRs, and any other data source connected to the provider’s Wi-Fi. Holon then presents the most relevant information in an unobtrusive ribbon next to the electronic chart. (Holon was a winner in the 2018 Healthcare Innovation Innovator Awards Program in Value-Based Care: Vendors Division.)
Dietzman said that while the HIE is collecting millions of clinical messages every month and creating an ocean of data, most of the tools available to surface relevant information are fairly blunt. “Holon is going to allow us to leapfrog the technology and say if it is an oncologist using the tool or one of their staff, rather than giving them a generic view of the clinical record, we can give them information that an oncologist would be interested in seeing. The view would be different from someone working in a behavioral health space.” That ability to be more specific in how data is presented based on context without them needing to ask is a game-changer, he said. “We know who they are, so we are going to start putting information in front of them that is relevant without having to get the EHR involved.”
