Over the past couple months, Unite Us has been interacting with different CMS grantees who have been trying to figure out how to report success and impact metrics back to the government. Based on our conversations we noticed a theme; everyone was defining the same terms differently.
Here are four commonly misused terms and what they mean in the context of community-wide care coordination:
1.) Community Based-Organization (CBO): If it falls into the category of health, human or social services it's a CBO. Most healthcare providers are only looking through the lens of clinical SNF, Home Health, Pharmacies, etc. But you must also include those human and social services, housing, transportation, food insecurity, employment, legal, etc.
2.) Care Coordination (Probably better characterized as "Community-wide Coordination"): Coordinating care across BOTH clinical and non-clinical social services. Inevitably, as soon as we mention care coordination, most hospitals immediately say we already have a care management team doing this. In a clinical setting, they are correct. In the context of addressing the social determinants of health, they are incorrect. Health care providers must have a platform that can extend their EHR into the community. As an example, the CMS grant requires grantees to assess a patient's social determinants, then connect said patient to said service, requiring COMMUNITY-WIDE care coordination.
3.) Referral: Simply put this defines something in transit. Organization-A will send a digital "referral" to Organization-B. You’ll need to proceed with caution, being wary of the anemic referral. Anemic referrals are nothing more than transactions, handing a patient contact information or a "resource directory" to a community-based organization (employment, transportation, behavior health, or food pantry provider). Only handing a patient service provider information is the old school approach, without community-wide infrastructure there is no scalable way to know if that patient went to said service, received said service, or if their issue was resolved.
4.) Case Management: When Organization-B accepts a "referral" in the above scenario, it converts into a case. Until they reach an outcome, Org-B will manage the patient through their internal process. When most hospitals think of addressing the social determinants of health, they tend to forget the importance of case management. To ensure positive outcomes, you need an easy way to receive this data from your CBO without creating an administrative nightmare for yourself or the CBO (manual follow-ups and death by excel sheets = admin nightmare). Your community-wide care coordination tool (if they're good) will have a strategy for this that doesn't require you or your CBO's to search through free-text outcomes. Your EHR and HIE aren't solutions for community-wide coordination since they are only focused on clinical providers. They aren't going to take the time to make sure housing, legal, employment, transportation, etc... are on their system, and frankly these service providers won't use your clinical tool anyway.
Unite Us provides the technology infrastructure to support community wide care coordination. Our collaborative software coordinates care to address the social determinants of health to improve health outcomes. If you are interested in learning more, fill out the form below and connect with our community-wide care coordination experts.