Health Information Exchange Helps Drive Accountable Care in Colorado

True innovation is happening all over Colorado in our health systems and communities. Throughout the state, there are many examples of people coming together in a community to tackle lowering health care costs and improving patient outcomes. One such group is Community Health Partnership, a coalition of health care providers working together to coordinate care for approximately 89,000 patients in the central area of the state, many of whom have multiple conditions requiring care by multiple doctors.

The organization was formed in 1992 in the Colorado Springs and surrounding areas as a partnership between behavioral health, physical health and hospital providers to improve care delivery. This early grasp of the “whole person” care coordination model makes Community Health Partnership an innovator in Colorado. They now have 25 organizations working together on patient-centered care coordination, including AspenPointe, Memorial Health System, Peak Vista Community Health Centers and Penrose-St. Francis Health Services.

Unique Patient Population Creates a Different Set of Challenges

Community Health Partnership was chosen to lead the Medicaid Accountable Care Collaborative in the area, becoming the Regional Care Collaborative Organization (RCCO) for region 7, which includes El Paso, Elbert, Park and Teller counties.

Medicaid beneficiaries, more than any other population, tend to use emergency services instead of their regular providers. In fact, a study by the University of Colorado School of Medicine shows that Medicaid covered patients had the highest rate of emergency department usage in the state, at 39.7 percent. The most common reasons cited were that care was needed after normal office hours and the patient was unable to get an appointment with their regular provider. And as we know, this is costly for the health care system when less expensive alternatives are available.

Unnecessary emergency department usage is the main challenge the Care Coordinators at Community Health Partnership are tackling. Not only are they helping Medicaid patients navigate their health conditions, they often have to get creative to make sure these patients can get to the doctor and not use emergency services. Whether it’s offering travel assistance in the form of gas cards, helping to arrange child care or food assistance, this dedicated team does whatever is in their power to make sure their patients get the care they need.

“There’s so much involved, it’s not just about medical care,” says Laura Thomas, Care Coordination Manager at CHP. “It’s about all of the other things that can prevent people from receiving the best medical care. You go in as a nurse thinking we need to help them with their diabetes or manage their asthma and that’s just the tip of the iceberg. It’s making sure people have food, transportation, housing -- it all contributes to their health.”

Access to Community Health Record Fills in the Gaps

One of the issues Community Health Partnership was having is that more than 25 percent of their Medicaid patients were not attributed to a primary care provider, making care coordination a challenge. If patients are not forthcoming about acute-care visits or don’t know pertinent details, getting the whole picture of their care was nearly impossible.

“So we turned to CORHIO to give us access to hospital data, which is a big part of what we were missing,” says Joel Dickerman, DO, Chief Medical Officer for Community Health Partnership. “We were looking for one-stop shopping so we could avoid reaching out to each hospital individually. A lot of our clients get their care outside of the Colorado Springs area, so we needed access to multiple communities. We had no idea of the magnitude of that until we got on CORHIO.”

“If we look up the patients and see that they don’t have a primary care physician, we can reach out to them to see what the challenges are and help them get access,” says Thomas.

Information From the HIE Helps Avoid Hospital Readmissions

Community Health Partnership is already seeing the HIE have a positive effect on unnecessary hospital admissions or readmissions. “The first thing we have to realize is where these people are going for their care so we can intervene if they’re going to the ER instead of a primary care doctor,” says Dickerman. “We contact them and ask if we can do something to help them not go to the ER for routine care.”

“In the past, we could only look at a few hospitals and now we can look at the whole system. And more importantly, we can look at the actual visit and see what it was for. We can read the whole record and see that maybe the diagnosis isn’t the whole story,” says Dickerman. “We can contact the patient and walk them through how to avoid this happening again. Maybe they didn’t have access to their meds or couldn’t get to their doctor’s appointment. Now we can start a better conversation with the patient and say: How can we help you deal with the cause that sent you to seek this care?”