Guest Column | October 9, 2018

Improving Community Health With Digital Care Coordination

By Tom Cox, MyHealthDirect

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As communities across the country face their own socioeconomic and health challenges, it is not uncommon for hospital emergency departments (ED) to be overcrowded and overutilized, particularly by under- or un-insured patients with non-emergent care needs. There are many reasons for this ED overuse and misuse, but a lot of times, it is simply due to patients’ lack of awareness of the safety-net and free clinics available to them in the area.

When being discharged from the ED, care managers refer a patient to a primary care physician or specialist for follow up care. Unfortunately, the referral process is often an outdated and inefficient one where patients are handed a sheet of paper with a list of physicians to contact on their own time. Left to schedule an appointment on their own, it is no wonder that one-third of patients never follow through on their referral. Not only do patients feel less empowered to follow up on their own, but this puts the ED and hospital at even more risk for readmissions. Moreover, when patients don’t have commercial insurance, they often feel uncomfortable with navigating the complex healthcare system to find care they can afford.

Fixing this problem by doubling down on the current paper-based system is a daunting and insurmountable task. Thankfully, technology has begun to open doors into new methodologies and capabilities to better coordinate these types of referrals.

We know, and have seen firsthand, the ways in which healthcare technology can improve community health—specifically in ensuring that low-income, medically underserved patients are connected with the right primary care physician.

For example, the coordination of discharge referrals can be vastly improved with digital scheduling. Care managers in the ED can digitally connect and schedule a patient for a follow-up appointment with a local medical home at the point of care, before the individual even leaves the four walls of the hospital.

No one knows this better than the city of Milwaukee, an early adopter of digital care coordination, that has been using the technology to connect its vulnerable populations to the right care providers and specialists since 2007.

The Milwaukee Emergency Department Care Coordination (EDCC) Initiative uses transition care management processes, powered by  MyHealthDirect, to connect patients in the emergency department (ED) with the appropriate, community-based care services. When patients are discharged from the ED, they are provided with a menu of options for providers and available appointments, as well as the guidance required to make an informed and appropriate decision for their situation.

The Milwaukee Health Care Partnership, built around the EDCC, is devoted to connecting the community’s vulnerable and underserved populations—including Medicaid patients, low-income individuals, and the uninsured—with home health services and primary care providers in their respective areas.

The results of these programs are irrefutable. Since 2012, more than 50,000 vulnerable individuals have been connected to primary care providers in Milwaukee, thanks to the foundation laid by the EDCC initiative and the technology that allows seamless communication and coordination between providers. With it in place, appointments are completed within 7-10 days of the initial appointment request. This has also led to a 44 percent drop in subsequent ED visits for those patients that kept their primary care appointments. Milwaukee hospitals can more effectively devote their ED services to patients in crisis who need it the most, while those with non-emergent care needs can rely on better, faster, and easier access care providers. 

The benefits of digital care coordination extend far beyond Milwaukee’s vulnerable patient population. The state of Virginia recently unveiled its EDCC initiative, which also aims to improve the exchange of patient data and information between hospitals and other health providers across the state. The goal is for each individual patient’s medical records and data to be accessible by a myriad of providers in real-time. 

Imagine if every community could quickly and easily connect all patients to the type of care that was right for them, while simultaneously avoiding the inefficiencies, mistakes, and crises of miscommunication and misalignment. Imagine if we could virtually eradicate medical lapses caused by bad information. With digital care coordination in place, a community’s providers are armed with the information they need to make referrals for patients, and the risk of misdiagnosing or overprescribing is significantly lessened. This is a win-win situation for all involved.

While some in the industry and in government debate the need for EDCC initiatives, our team is looking to the measurable and substantial outcomes derived from communities that have already taken the leap. We’re also applauding and watching the communities, like the state of Virginia, that are progressing in the same direction. Our hope is that the success of existing programs will serve as a model and a blueprint for other communities across the nation that want to improve the health of not just a few, but of the whole.

About The Author

Tom Cox is the CEO of MyHealthDirect.