Innovation in Care Coordination: Bridging Gaps for Better Patient Outcomes

Care coordination plays a pivotal role in improving outcomes, particularly for complex patient populations in today’s evolving healthcare landscape. During a recent presentation with OPEN MINDS healthcare leaders shared valuable insights into innovative care models capable of transforming the way care is delivered across the United States.

Dr. Lisa Benson, a supervising psychologist from the Los Angeles County Department of Mental Health and AJ Peterson, Senior Vice President at Netsmart, highlighted several groundbreaking models reshaping care coordination across diverse communities. Their focus? How community-based care and innovative technology can bridge critical gaps, especially for underserved populations.

The Growing Importance of Care Coordination

With the shift toward value-based care, care coordination has emerged as a critical component of healthcare delivery. In a value-based system, success is measured not only by the quantity of services provided but by the quality of outcomes achieved. For populations facing complex health needs—ranging from mental health issues to housing instability—the need for seamless care coordination is urgent.

In Los Angeles County, home to nearly 10 million residents, care coordination has become essential. The county's Department of Mental Health, under Dr. Benson’s leadership, serves more than 240,000 unique clients annually. Many of these clients face overlapping health, social and behavioral challenges. Care coordination ensures that services are delivered efficiently, making it possible to meet both individual and community-wide needs.

Technology's Role in Transforming Care

Technology like the Netsmart CareFabric platform is the backbone of modern care coordination models, enabling providers to manage care across multiple systems and stakeholders. The Netsmart Population Health Management solution is a part of the platform, used in Los Angeles County and other regions, exemplifies this innovation in care coordination. The solution integrates data from various sources—including health records, social services and criminal justice systems—to create comprehensive care plans. This data-driven approach empowers case managers to make informed decisions about each patient’s needs.

Data-Driven Decision Making

The success of care coordination hinges on real-time access to actionable data. For instance, case managers in Los Angeles County use the Netsmart Population Health Management solution to receive instant notifications when clients experience significant life events, such as a hospital admission or a change in housing status. These alerts allow care teams to intervene swiftly and ensure that patients receive timely, targeted care.

The solution’s ability to aggregate data across various systems—behavioral health, physical health and social determinants—enables providers to develop a holistic view of each patient. This level of insight is particularly valuable in managing high-acuity populations, such as those with co-occurring mental health and substance use disorders.

Overcoming Barriers to Care

The presenters also emphasized the importance of partnerships in overcoming barriers to care. Whether it’s working with managed care plans to deliver enhanced care management services or partnering with technology firms like AWS to build scalable, secure infrastructure, collaboration is key to advancing care coordination.

In California, programs like Enhanced Care Management (ECM) and Care Court are making significant strides. ECM, for instance, provides comprehensive care management to Medicaid beneficiaries with complex needs, ensuring they receive both medical and social services. The Care Court initiative, meanwhile, seeks to connect individuals with mental health needs to services before they become involved with the criminal justice system. These programs are designed to reduce health disparities and improve access to care for some of the state's most vulnerable residents.

The Future of Care Coordination

Looking to the future, the potential for predictive analytics and augmented intelligence in care coordination is limitless. By analyzing data from various sources, these technologies can help providers anticipate patient needs and prevent adverse outcomes, such as hospital readmissions or mental health crises.

For example, the Netsmart Population Health Management solution is going to assist Los Angeles County with more predictive analytics to help determine impacts on hospitalizations based on detailed data models. As technology continues to evolve, the ability to use data not just for reactive care but for proactive interventions will become a powerful tool in the fight to improve patient outcomes.