A partnership that includes five health systems in Dane County, Wis., is working with Epic Systems to embed social needs screening and a community resource directory for referrals directly into their instances of Epic.
Connect Rx Wisconsin recently won $1 million to help build a community information exchange in a contest sponsored by Schmidt Futures, a philanthropic initiative founded by Eric and Wendy Schmidt. The team proposes a fully integrated network of healthcare and social service systems across Dane County that builds on existing electronic health record technology and community and medical providers. Partnering organizations include the Foundation for Black Women’s Wellness, United Way of Dane County, UW Health, Access Community Health Centers, Group Health Cooperative of South Central Wisconsin, SSM St. Mary’s, UnityPoint Health – Meriter, Public Health Madison and Dane County, and Madison Metropolitan School District, all of which are members of the Dane County Health Council, as well as technology partner Epic.
In a recent interview, Robin Lankton, director of population health at UW Health, said the main thing that distinguishes Connect Rx Wisconsin from other community information exchanges is that “the solution is embedded natively within Epic, and so our care team members don’t have to go to a web-based portal or a third-party vendor to access the information and do their documentation. We really think that the uptake and acceptance and operational success will be much higher because it is embedded in Epic.”
“I do think we have a unique opportunity with Connect Rx Wisconsin because Epic is in our backyard,” she said. “We are excited to be the test case and hope that the model can expand to other places. I know our health system leaders were particularly interested in creating a solution that was embedded within Epic.”
The initial focus is prenatal care, and the timeline for Connect Rx Wisconsin’s proof of concept is that by the end of 2022 they want to reach at least 10,000 households, and the goal is to increase their household income by 10 percent by connecting them to more economic resources. “We think the build will take nine months, and we want to start the rollout with the community-based teams midway through 2021,” Lankton said.
The team has been working on developing the solution for about three years. “The origin of the work is that Wisconsin has some of the worst inequities in health and economic opportunity in the country,” Lankton explained. “We have among the worst maternal and child health outcomes and some of the worst disparities in household income in terms of African-Americans compared to our overall population. The work is really powered by a collective called the Dane County Health Council, which is a multisector partnership representing community partners. We were looking at root causes of health and economic inequities and we realized we needed to screen people about social needs and then get them connected to resources.”
One partner is United Way of Dane County, which operates the 211 community resource directory, connecting with more than 5,000 community-based agencies. “We will screen people for social needs when they come in for medical appointments,” Lankton said. “We know that between us these health systems provide prenatal care to 99.6 percent of patients in Dane County. We will search the 211 electronic community resource directory, which will be embedded in Epic, and we will be able to send an electronic referral to community-based organizations. We also are hiring a community-based work force of community health workers, doulas and healthy birth ambassadors, so the highest-risk patients will have a support person helping them navigate the system.”
The Connect Rx Wisconsin team is in talks with the state’s Medicaid program, called BadgerCare, about participating. “There is a new BadgerCare performance improvement plan requirement that health plans must cover what they call nontraditional prenatal care providers including community health workers and doulas,” Lankton said. “We are in conversations with our local health plans now to see if we can build in the reimbursement model starting in 2021 for the care coordination and community support members. We hope that will be part of the proof of concept, and we would like to expand to all of primary care as the next population in terms of screening and could eventually expand to inpatient and outpatient settings.”
Another goal is to see the model expand to all of Wisconsin. “We think it is a unique model because it builds on the combination of technology and community-based work force,” she said, “so we think it will be more successful than some of the models that are already out there, which rely exclusively on technology.”
In researching the concept, the Wisconsin group talked to people in the City of Baltimore, the State of North Carolina and the Twin Cities about their experiences getting things off the ground. “We have tried to bring in our IT stakeholders and chief information officers early in the process,” Lankton said. “One of the challenges when you are trying to do something collectively with technology is data sharing, and making sure we have the agreements in place in terms of health information exchange and data use agreements so we can share information.”
They are still working through details about clinical work flow. “We are proposing we could push out a screening ahead of time in the pre-visit,” she said. “We are starting with the prenatal population, which usually does have surveys or questionnaires people are completing ahead of time through MyChart. We are also planning to have tablets in the clinic locations so they can complete it there. We expect a medical assistant or nurse will verify the information with them. A social worker can make the referral through Connect Rx Wisconsin or that care team member can do it.”
In the current health system, because there isn’t a systematic approach to referrals, they are relying on individual people’s knowledge, which is widely variable. “This should create more efficiency with a standardized work flow and a standardized way to search for resources and a standardized way to match people to what they are eligible for,” Lankton said, “so it should save the clinic staff time rather than things coming up ad hoc and them not having a system to support them. This will be much better.”
For the community partners, one of the benefits is that they can access the data on how many patients they are receiving referrals for and how many they are “closing the loop” on. Sometimes they need that information for grants or for other quality reporting, Lankton said. “Also, they will not be getting referrals five different ways from five different health systems, but there will be one streamlined approach that should make it easier for them to fill referrals and track things.”
She said the team members are elated about winning the prize funding and believe that Connect Rx will help turn the tide on economic and health disparities in Wisconsin. “I think we have a great partnership to use technology and community organizations to address social needs and health. We are excited to test the proof of concept and expand when it is successful.”
Another project from the University of Wisconsin, called the Opportunity Calculator, also won $500,000 in the Alliance for the American Dream Challenge. Opportunity Calculator plans to develop a mobile platform to give workers fast, accurate information about how career and training opportunities could affect their net income, helping them achieve career goals and make positive financial choices. The platform makes it easier for employers and community partners to learn about benefits packages and employment opportunities and to address barriers to growing the workforce.
