Healthcare Network for Behavioral Health and Social Care - Challenges You Can't Ignore

Today’s healthcare, as served by multiple public programs, is often challenging for constituents to navigate. An uncoordinated system of care being managed by many different agencies and networks of service providers, with collection of duplicative information, competing and conflicting care plans, and inefficient data sharing makes the overall ecosystem fragmented with few warm handoffs, especially when it comes to referrals.

This blog explorers how a supportive technology solution for health and human services aligns with the healthcare system’s common vision, strategic directions/goals, and priority initiatives with respect to addressing the immediate care coordination challenges and advancing intra and interjurisdictional interoperability will help patient communities achieve faster and better outcomes.

Challenge: Ineffective Care Due To A Fragmented Healthcare Ecosystem

People served by one organization in a community are commonly co-served by other organizations, such as behavioral health, child welfare, school, and justice among a few. People most in need of care must tell and retell their story to multiple providers and often experience poor outcomes. Those providing care have to maintain their records internally in order to maintain confidentiality. The lack of collaboration arises due to different electronic record systems capturing data in different formats and ways. All of which results in an uncoordinated care system where it is difficult for the health agencies to determine whether the right level of care is being delivered or measure the overall impact of care delivery and access.

Solution: Enhancing Collaboration And Coordination Among Care Organizations Through A Centralized Care Network

The Infosys-Opeeka Centralized Care Network unifies information across all care organizations in a county, state, or any jurisdiction. With the Centralized Care Network, organizations can flexibly and easily collect information about people receiving care, share what is needed across different providers, and monitor outcomes in real time.

The Centralized Care Network is designed to enable warm hand-offs or ongoing teaming with flexible and judicious sharing of information. The system can ingest and display all person-centric data from other systems of records, such as provider data, claims data, referrals, and test results, and relate it back to a unified patient record. Once calibrated, the data exchange is enabled within care circles. Information is shared for co-served individuals, for just the agreed and released elements of information, for just the times when those people are co-served. Workflow continues within native electronic systems at each organization. Through its connections, Centralized Care Network identifies when people are co-served helping agencies and network providers to determine eligibility, level of care, rate of reimbursement, cultural preferences, level of need, areas of strength, past experiences, diagnosis, progress, satisfaction, and final outcomes.

Improving Care Coordination And Outcomes

More data can help deliver tailored healthcare services, but at the same time, various components of healthcare data (if not correctly organized and served) have the potential to compromise healthcare delivery, quality, service efficiency, cost, and can increase the chances of medical errors.

For example, a child’s access to mental health care is often difficult to coordinate due to restricted pathways and lack of information sharing/availability at the point of care. A care organization for outpatient mental health might not know about or have access to the same screens or assessments already performed by another organization, such as emergency care or inpatient care. Since the process for screening, assessing and determining care are specific to a care organization, for every visit, the families or case managers must fill out the same set of health screening and assessments (multiple times based on the different care providers they visit) to access a necessary component of care. This results in duplication and unnecessary rework. These processes also evolve as policies and population care delivery needs adjust over time. In contrast, a centralized system which facilitates universal access to screening, assessment, and entry to care must be flexible to accommodate a wide variety of processes and must be adaptive to adjust over time to meet the needs of all organizations in a unified system of care.

To address this need, the Infosys-Opeeka solution focuses on creating a unified “command center” with a centralized data hub, providing deep insights, advanced analytics, and interoperability for better usability of healthcare data. This ensures sharing of information for coordinated care delivery across the entire care network. The solution aggregates and manages any type of healthcare data (EMR/EHR, lab, screen, or assessment forms, etc.), creates a 360-degree view of entities in the full context of care, and applies level of care and rate determination AI algorithms to produce recommendations/next best actions for the care providers. When screening or assessment processes change, local agencies and care providers can directly configure changes in their control center to adjust the process across care – just in time.

Additionally, through robust security compliant and interoperability (FHIR and beyond) technology, the solution supports sharing of screening, assessment, goals, and outcomes information within a care network. When two or more agencies agree to collaborate to serve patients for certain types of care, each organization can designate exactly which programs/practices, which contingent screens/assessments, and which contingent data elements to share, for which individuals, and under what circumstances.

In this way, when a patient presents for care, a care organization that is part of a care delivery network (as set up within the Centralized Care Network) can search for that person and access any legally shared screens, assessments, outcomes, and goals for that patient — for just the information that was released (not data that was redacted). If a screen or assessment was recent, then the patient does not need to undergo a similar procedure/assessment again. In addition, patient goals can be shared and aligned. Any additional information can be shared back by partnered care organizations co-serving the patient. Notes related to that screen or assessment can alert the care partner about complementary care, and the staff can work together to coordinate plans.

Conclusion

The Infosys-Opeeka Centralized Care Network solution enables care organizations to enact person-centered care across a unified system of care organizations. This coordinated care system also enables real-time visibility into patient outcomes, HEDIS measures, and cost of care. It also promotes health equity. The solution benefits the administrative staff as they receive instantaneous feedback for authorizations, spend less time on documentation, and see evidence of the positive impact they are making. Every stakeholder involved in care delivery can make data-informed decisions, reducing bias in decision processes, and providing more effective and equitable care at lower costs. Improved care delivery and more productive staff reduce the cost of care, and at the same time, make the system more responsive to the changing needs of their population.

Author Details

Kate Cordell, PhD, MPH - President & Co-Founder, Opeeka

Dr. Kate Cordell is a Principal Investigator, a health services data scientist and researcher. Dr. Cordell is a nationwide thought leader for behavioral health technology, integrating data systems to support a whole- person approach to care.

Dr. Suman De, Head of Government Healthcare Analytics, Infosys Public Services

He has extensive experience in the public healthcare sector and previously worked for the World Health Organization, UNICEF and the Indian Public Health Association. At Infosys, Dr. De leads the area of advanced data science and artificial intelligence-enabled population health, social determinants of health analytics, opioid management, care management, and value-based care.