This presentation will demonstrate how multi-provider collaborations can use interconnected health information systems, specialized patient support, and interdisciplinary teaming to improve care of individuals with complex behavioral health (BH) needs. By discussing the Camden Coalition’s “Pledge to Connect” model and exploring its core components, attendees will learn how to design data-powered ecosystems of care to better support patients with frequent utilization of multiple EDs. Attendees will also learn how to build the program’s foundational elements, such as strong patient consent practices, data segmentation protocols, thoughtful workflow design, and interdisciplinary teaming. Presenters will lead an interactive discussion on the criticality of health information exchange in coordinated transitions of care between health systems and community-based BH services. Because data between providers does not facilitate continuity of care, providers in Southern New Jersey utilize the Camden Coalition’s HIE to identify patients presenting in several regional EDs with BH needs. Key patient information is transmitted between multi-site teams and used to develop shared care plans focused on ED diversion services and community-based care. The HIE provides care teams access to comprehensive patient data from health systems, federally qualified health centers, the department of corrections, and out-patient behavioral health providers, and produces automated lists of patients with high ED utilization and unmet BH needs. Care team utilization of HIE data and its analytic tools maximize workflows and enhance chart reviews, which enable them to understand individual patients’ journeys and the need for specialized support. Evaluations demonstrated that this model increased patient connections to outpatient community-based BH services in a timely and equitable manner. For example, an analysis showed that patients who received follow up from a behavioral health navigator got connected to services within a median of 5 days, and most participants had a claims-based appointment within 30 days.
(1) how to leverage a health information exchange and to activate health information exchange data to enhance regional care coordination between hospitals, behavioral health providers, and community-based providers
(2) data-based strategies to co-design, implement, and promote adoption of innovative models of care in collaboration with clinical and community-based partners
(3) how to navigate patient consent to develop thoughtful workflows tools to support multi-provider shared care planning