Care Coordination

OeHI Care Coordination Projects

OeHI and the eHealth Commission are committed to the development of a Social-Health Information Exchange (S-HIE) infrastructure, defined as an interoperable and flexible infrastructure that supports coordinated whole person care across the physical, social, and behavioral health domains. 

S-HIE is an innovative model meant to include the social determinants of health in a person’s primary care. Through this model, when an individual shares their social needs with their primary care provider, the provider can make a referral directly to a social program in the community. For providers to connect patients to social services, multiple steps are required: screening and assessing for a need, finding a program in the community, referring and connecting the individual to the program, and confirming and recording the referral result (known as closing the loop). Each step presents an opportunity for technical solutions, from electronic screening tools to resource databases.

Our current S-HIE projects support technical solutions that share core components, data standards, and common practices for the meaningful exchange of social and health information. This will allow providers to use the tools that are most useful in supporting their patients while still exchanging relevant data across health and social systems. This data-driven infrastructure will reduce provider burden and promote efficiencies across systems, paving the way for improvements in health equity.

Our current projects will achieve three objectives: 

1. Demonstrate closed-loop referrals for social needs in multiple diverse Colorado regions.
2. Demonstrate interoperability between social care platforms.
3. Demonstrate population level analysis that improves decision making for care coordination. 

In addition to these objectives, key deliverables for our current projects include a functional architecture for S-HIE in Colorado, an enhanced statewide community resource inventory (CRI), and a community improvement project library. OeHI has partnered with three technical partners, Colorado Regional Health Information Exchange Organization (CORHIO), Quality Health Network (QHN) and Colorado Community Managed Care Network (CCMCN) to implement project activities across the state. 

Lastly, OeHI, in partnership with the Colorado Health Institute (CHI), is currently facilitating the Care Coordination Information Governance Task Force. These efforts focus on the adoption of open standards and the development of Colorado specific policies for information governance to direct the exchange of data for screening, referral and care coordination. These policies will prevent siloed data and advance interoperability as outlined in the 21st Century Cures Act aligns with the national Gravity Project’s standards.

About Care Coordination

The Office of eHealth Innovation (OeHI) and the Care Coordination workgroup have done extensive research to understand the current state of care coordination in Colorado. The established goal of the Care Coordination workgroup is to identify, understand, and prioritize leverage points to support whole person care by facilitating the connection of individuals to needed resources across Colorado communities using health IT infrastructure and data sharing. The workgroup defines whole person care as being comprehensive of behavioral, social, and physical health needs. OeHI aims to connect healthcare, human services, and community partners to build a social-health information exchange (S-HIE) infrastructure for navigating resources. Investing in SHIE infrastructure requires advancing multiple components simultaneously, including advancing shared practices for data governance, common workflows across collaborating organizations, and the adoption of interoperable technology. The overall vision of the infrastructure is to allow multiple entities to screen, assess and refer clients to resources, ensure clients access resources, provide case management when applicable, and evaluate the impact of resources on health and wellbeing.

Many efforts are underway in Colorado, including both for-profit companies and grant funded pilots, to bring disconnected partners together and connect clients to resources. OeHI is funding eligible entities under HITECH guidelines to advance infrastructure projects that support the overall S-HIE ecosystem. The OeHI funding strategy is to advance and connect the required components of the infrastructure, reduce duplicative technology systems, and facilitate information sharing within and across local communities through common data standards. We recognize that many initiatives are currently underway and aim to leverage prior investments and support local and regional efforts in scaling effective solutions.