Care Coordination

Right care, right time, right place.

Goal:

Enhance care coordination and navigation across the health care delivery system.

Strategies:

  • Enhance care coordination between emergency departments and primary care medical homes
  • Provide navigation support across the health care delivery system
  • Improve care management for individuals with chronic health conditions

Emergency Department Care Coordination

For many years, nearly half of emergency department (ED) visits in Milwaukee County have been for non-emergencies, with many of those visits made by uninsured or underinsured individuals lacking a primary care provider.  Since 2007, the Partnership’s Emergency Department Care Coordination (EDCC) initiative has worked to:

  • Decrease avoidable emergency room visits and related hospitalizations
  • Reduce duplicative emergency room tests and procedures
  • Connect high-risk individuals with primary care health homes and other health resources

The EDCC has demonstrated a 44% reduction in subsequent ED usage among patients connected to primary care.

Deploying a combination of standardized transition care management processes and health information technology, the EDCC initiative connects ten adult hospital EDs and more than 10 community clinics in Milwaukee County; facilitating the referral of about 500 ED visitors a month to primary care clinics.

Emergency department staff utilize the Wisconsin Statewide Health Information Network to identify patients previously served in emergency settings and avoid duplicative tests. They also use MyHealthDIRECT, a web-based appointment scheduling tool to secure a primary care follow-up appointment electronically, while the patent is in the ED.

The Robert Wood Johnson Foundation’s focus on appropriate emergency department use provides key lessons learned by regional alliances in their Aligning Forces for Quality communities – including Milwaukee – as they work to transform local health care and provide models for national reform.

Health Care Navigation

An emerging focus of the Partnership is to identify, prioritize and implement strategies to help low-income populations navigate the health care delivery system and help connect them to the ‘right care, at the right time, in the right place.’

With the expansion of coverage under the Affordable Care Act, there are about 46,000 newly insured Medicaid beneficiaries and more than 38,000 Marketplace enrollees in Milwaukee County — many of whom have challenges understanding or using their coverage. Often, they encounter other socio-economic barriers to accessing care such as transportation, housing, child care and health literacy.

The Partnership hosts a Health Care Navigation work group that is developing strategies to:

  • Connect and reconnect vulnerable consumers to care
  • Create community-based navigation strategies
  • Improve health literacy
  • Expand transition care management across the health care delivery continuum