Care Coordination in Action: Elevate Outcomes with Interoperability Technology 

My Health My Resources (MHMR) of Tarrant County is in Fort Worth, Texas. It is the second-largest community center in Texas and has been operating since 1969, providing services that include mental health, intellectual and developmental disabilities, child and family services, addiction and substance use, early childhood intervention and criminal justice support.

Recently, Daniel Skinner and I had the pleasure of presenting with representatives of MHMR of Tarrant County on how they use CareConnect Inbox, the Netsmart Direct Secure Messaging solution, and Carequality, an interoperability framework, to securely share health information – both externally with provider partners and internally with care team members.

Sharing information with provider partners — a core component of care coordination

Referring individuals to partner providers allows MHMR Tarrant County to provide individuals with the broad spectrum of care and services they need. The organization’s postpartum care program, for example, includes medical assessments for mother and child with an obstetrician and pediatrician, education on newborn care, health screenings (including mental health) and connections to other community resources.

To maximize the effectiveness of referrals and partnership with providers, MHMR Tarrant County relies on clinical reconciliation to make the information available to the individual’s care team. Internally, that means not just importing continuity of care documents (CCDs) but parsing out information so that it’s in the appropriate sections of the electronic health record (EHR), in this case myAvatar.

Instead of having to click on the CCD to find, for example, medications and allergies, the information is displayed in a fashion that would be expected by the end user of the EHR. This helps ensure that critical information isn’t missed, supporting improved outcomes and client satisfaction.

Care coordination in action – a real-life example

An individual received services at a medical facility. Upon release, they sought mental health services from MHMR Tarrant County. Using the CCD obtained through Carequality, the care team at MHMR Tarrant County could see the individual’s extensive history with other hospitals, including medication history and allergy information, and make informed decisions that significantly impacted the care plan.

The CCD also provided a clear picture of what the individual had been going through, allowing MHMR Tarrant County staff to pull key information forward, review it and immediately reconcile it with their records. The impact went beyond streamlining information for the medical team. Using customizable widgets, key data was also made available to the organization’s financial support team and caseworkers.

The client experience was improved as well. Because their information was documented in the EHR, they didn’t have to repeat answers to the same questions they’d been asked at the hospital or for each member of their care team at MHMR Tarrant County.

Establishing the need for better care coordination

Several years ago, the technology team at MHMR Tarrant County realized their organization was not taking full advantage of myAvatar, their EHR, and the care coordination possibilities of CareConnect Inbox and Carequality. They began a concerted effort to establish a care coordination culture within their organization.

Resistance to change was a barrier. But there also was an overall reluctance to sharing information widely with so many organizations, despite the acknowledgement that such sharing could elevate the quality of care and benefit clients. The technology team made a persuasive case that receiving referrals and sharing information through Carequality and CareConnect Inbox was HIPAA-compliant and more secure than current methods, which often involved email and faxes.

As a result of these efforts, outgoing information requests from MHMR Tarrant County to partners increased exponentially. Incoming requests from provider partners also exploded: the organization now receives an average of 4.3 million Carequality information requests per month. ***Data from June 2023 to January 2025

Setting the stage for closed-loop referrals with 360X — completing the care coordination circuit

MHMR Tarrant County is currently working on a pilot initiative with Netsmart, Epic and a local children’s hospital to share information and referrals. Using 360X electronic closed-loop referral management standards, the project automates the referral and follow-up process with the exception of acceptance or rejection.

360X is a set of interoperability standards that sits on top of Direct Secure Messaging. The necessary information is “pushed” from the referring clinician’s EHR directly into the receiving provider’s EHR. Once the consultation has been completed, the information is “pushed” back to the referring physician, thereby closing the referral loop. Clinicians are informed if individuals kept their appointments, what treatment took place and when.

Because they’re already using CareConnect Inbox, the Netsmart Direct Secure Messaging solution, organizations like MHMR Tarrant County can make a smooth transition to closed-loop referrals and reap even greater benefits with a higher level of interoperability. 

MHMR Tarrant County has a fascinating story to tell about their journey to increased interoperability and how they intend to continue improving care coordination and information sharing. To learn more details, watch the full presentation here.

Ben Rosen is a senior client success manager and business unit owner for the interoperability solution suite at Netsmart. With more than a decade of healthcare experience, Ben has led numerous initiatives to integrate healthcare systems and enhance data sharing across the care continuum. His dedication to advancing healthcare interoperability drives his active involvement in industry initiatives and standards organizations, where he provides insight for frameworks such as HL7 FHIR, USCDI and others. Ben holds a Bachelor of Science in kinesiology from Kansas State University and a Bachelor of Science in nursing degree from the University of Nebraska Medical Center.