Thursday, April 22 | Human Services, Care Coordination, Value-based Care

Serving the Underserved

By Netsmart

There is a lot that goes into delivering quality healthcare to individuals. While the goal is to serve one and all, factors such as complex conditions, homelessness, unemployment and access to care can still leave populations underserved.  As providers work to improve outcomes and reduce health disparities, it’s important to they have the tools to do just that. The ability to seamlessly share data, implement a strong virtual care strategy and integrate services across the care continuum can be imperative to meet these goals.

Dr. Dennis Morrison, PhD, Neal Tilghman, MPA and Tricia Zerger, MA discussed the importance of not only reaching underserved communities, but offering holistic, data-driven services regardless of where care is being delivered.

Integrated care: What’s the big to-do?

“We can’t just look at a person in a silo anymore and say my job is behavioral health, and physical and social health goes elsewhere,” Morrison said. “That’s just not the case anymore.”

Integrating care leads to better health outcomes, increased operational revenue and expanded service lines. This has never been more important, and the statistics speak for themselves. 40% of US adults report having a mental health or substance use disorder, and one in 12 people rely on Federally Qualified Health Centers (FQHCs) for care. Between 30-80% of primary care visits are driven in part by behavioral health issues, and nearly half do not follow up with a mental health specialist after referral from their primary care provider. These numbers display the importance of integrating primary care and behavioral health services.

Ideally, behavioral health services would be available within the primary care facility, however this isn’t always feasible due to staff shortages or physical distance. Therefore, organizations can leverage both integrated technology and virtual care options to ensure the individual is seeking appropriate additional care post visit. Technology that allows the primary care provider to share health information with other providers, paired with alternative care options such as telehealth, better supports individuals in underserved communities.

While integrated care is not necessarily new, it’s important for providers at all service levels to understand the opportunities and not limit themselves by a typical definition of integrated care.

“Sometimes we fall into a trap of having a very narrow definition of integrated care,” Tilghman said. “But today there are multiple permutations of how we integrate care, which can help us advance serving the underserved.”

There are four recommendations organizations can take to integrate care:

  • Integrate physical and virtual care with outside providers: This approach is similar to the example above, with behavioral health services being made available within the primary care space. When physical presence is not viable, organizations can use data sharing tools and virtual care options to connect with outside providers who can make informed and accurate decisions based on shared documentation, regardless of setting.
  • Human services organization partners with a primary care provider: In this case, providers can partner with an FQHC, merge with an FQHC or even become one themselves. This reorganization ensures individuals are cared for holistically within one provider unit. It’s a seamless transition for the consumer and helps prevent potential gaps in care.
  • Become an integrated care system: When organizations become actual integrated care systems, they can facilitate risk-based contracting and manage complex populations. Serving as an integrated care system not only cares for individuals, but for specific populations and the community health as a whole.
  • Use solutions that compliment or expand the electronic health record (EHR): To successfully integrate care and prosper in a value-based market, providers must use solutions that compliment or expand the EHR.

Going beyond the EHR

Providers across all service lines need solutions that capture data at the point of care, regardless of where or how its delivered, especially as virtual and home-based care continue to grow.

Data-driven platforms that allow organizations to manage a diverse workforce, predict and mitigate risk, and support alternative payment models are vital in achieving population health management, and in turn effectively treating underserved communities.

Just as technology must go beyond the EHR, organizations’ virtual care strategy must go beyond telehealth. Digital self-help tools, dictation tools, electronic visit verification (EVV), mobile capabilities and screening tools are just some of the solutions organizations can implement in addition to telehealth.

Virtual care is here to stay, therefore optimizing additional solutions to diversity your virtual portfolio will expand access to care, coordinate services and improve outcomes, especially for those in underserved populations.

The biggest takeaway?

Integrated care works – and it’s essential to meet the needs of underserved populations, addressing social determinants of health and positively impacting outcomes and revenue.

“Technology is powerful and is critical to whole person care,” Zerger said.  “Find a partner and platform that delivers solutions and services that capture the full picture of a person’s health. This includes everything from behavioral health, addiction treatment and primary care.”.

Webinar presenters also discussed the importance of population health analytics (30:00), health status monitoring (45:00), policy and advocacy regarding integrated care (47:00) and more. Check out the whole webinar here.



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