Kirk Smith, President and CEO of the Greater Flint Health Coalition (GFHC) and Doug Dietzman, CEO of Great Lakes Health Connect (GLHC) will collaborate in delivering a presentation at the 2020 Health Information Management Systems Society (HIMSS) 2020 Global Conference on Wednesday, March 11 from 11:30am – 12:30pm. The title of their presentation is, Leveraging HIE in Building Clinical Community Linkages to Improve Social Determinates of Health Engagement and Reduced Emergency Department Utilization (Session ID: 143).
Clinical-Community Linkage Model
In 2017, the Centers for Medicare and Medicaid Services and the Michigan Department of Health and Human Services selected the Greater Flint Health Coalition, as one of five convening entities to implement a State Innovation Model (SIM) initiative in Genesee County. Two main goals of the effort were to reduce emergency department utilization, while addressing the social determinant needs of the target population. GFHC designed a clinical-community linkage model incorporating 41,000 Medicaid qualified adults across the region. The collaborative effort also engaged local physician organizations, Medicaid health plans, hospitals, specialty hubs, and a collective of community and social service organizations.
Great Lakes Health Connect (GLHC) became a partner in this important work. GLHC provides custom reporting on targeted populations and deployed a closed –loop network, electronic referral solution to enhance communications and streamline processing between the various collaborating entities. GLHC also identifies high emergency department utilizers by analyzing Admission, Discharge, and Transfer (ADT) notifications. Four area hospitals provide this information. GLHC selects patients who have had five or more emergency department visits within the most recent month. Then compiles and provides GFHC with the list of those patients who have a documented relationship with a Patient Centered Medical Home (PCDH) practice in the county.
SDOH Screening Strategy
Greater Flint Health Coalition also created an SDOH screening strategy. This plan consists of a standardized survey tool embedded into the electronic medical record systems of over sixty PCDH practices. Caseworkers within the practices administer the screening. It asks about a variety of SDOH factors that might be contributing to patients’ high ED utilization. By analyzing patient ED utilization data alongside the SDOH screening results, more appropriate community-based interventions can be identified and referrals can be made to the appropriate agencies. All referrals are managed through the GLHC referral solution. It connects all participating practices, specialty hubs, and community service agencies. In this way, ED utilization is proactively reduced and underlying social needs and barriers are identified and addressed. This results in more positive health outcomes.
Since November of 2017, approximately 25,000 SDOH screenings have been completed across Genesee County. Of those, 85% of all SDOH referrals have been satisfactorily resolved through collaborating partner organizations. In addition, Emergency Department utilization among patients attributed to participating PCMH practices has been reduced by over 15%. Participating SIM PCMH practices in Genesee County have the lowest rates of ED utilization among all SIM practices in Michigan. As a result of the positive outcomes reported across all five community health innovation regions in Michigan, CMS has approved the continuation of funding for the State Innovation Model initiative.
The HIMSS conference will be held at the Orange County Convention Center in Orlando, Florida, the event is the largest annual gathering of health information technology professionals in the world. It attracts nearly 45,000 attendees and over 1,300 exhibitors each year.