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Linn County officials announce care partnership 'My Care Community' to improve health outcomes

My Care Community a collaboration of health care, social services

Pramod Dwivedi, Linn County Public Health Director, speaks at a press conference the Jean Oxley Public Service Center in Cedar Rapids Thursday, April 18, 2019. Linn County Public Health has announced a new effort with 19 area agencies to share data, streamline patient referrals and improve community health outcomes. (Michaela Ramm/The Gazette)
Pramod Dwivedi, Linn County Public Health Director, speaks at a press conference the Jean Oxley Public Service Center in Cedar Rapids Thursday, April 18, 2019. Linn County Public Health has announced a new effort with 19 area agencies to share data, streamline patient referrals and improve community health outcomes. (Michaela Ramm/The Gazette)
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CEDAR RAPIDS — Local health care providers say they often struggle to address an individual’s needs outside the clinic, such as access to housing and transportation.

In an effort to address the whole person, a new partnership among county officials, health care providers and not-for-profit service agencies was formed to better streamline patient access to services.

“We wanted to create a ‘no wrong door’ model where a client could get access to this system to any of our partner organizations,” Linn County Public Health Director Pramod Dwivedi said.

An initiative called My Care Community was announced by Linn County Public Health Thursday as a partnership among 20 area agencies to share patient information and streamline client referrals through an electronic system called TAVConnect.

The system, which is HIPAA compliant, would reduce client burden and ensure they are receiving the care they need, said Jamie Henley, Community Health Free Clinic chief operating officer and chairman of My Care Community.

“My Care Community has laid the foundation to build bridges between sectors and to break down silos,” Henley said.

Henley explained that, under this system, Cedar Rapids hospitals would have a direct referral path to mental health services, for example, or a low-income diabetes patient who lacks transportation would have a direct path to transportation services to ensure they never miss an appointment.

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“Our low-income population, those are the folks that most of the organizations (in My Care Community) serve ...,” Henley said. “So that’s really the population that needs the most help.”

In addition, providers within the collaboration will know if a patient they referred to other agencies actually received additional services.

“There was nothing in place to close the loop, which made it more difficult to fulfill ongoing clients’ needs and care,” Dwivedi said. “Care organizations were finding that work was being duplicated and opportunities for collaboration were missed.

“I know our clients are frustrated with the cumbersome and confusing process of trying to find the help they needed, often while in crisis, and having to tell and retell their story to so many different organizations,” he added

Clients sign a release to have their information shared among agencies through the system. Henley said medical information won’t be shared with social service organizations.

Clients can request a referral, or a provider may recommend additional services after the client completes a needs assessment.

Dwivedi said the effort began in 2016, when Linn County Public Health was awarded a $250,000, three-year grant from the federal Centers for Medicare and Medicaid Services.

Officials created a community care coordination system to assess social determinants of health among Linn County residents, such as access to transportation to doctor’s appointments, food insecurity and safe housing.

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“We found there was a lack of knowledge or feedback around referrals,” Dwivedi said. “Providers were curious about what happened to their clients once they left the organization.”

Though the federal grant funded the start of My Care Community, the collaboration now is self-funded by participating agencies and Linn County Public Health is providing staffing for the initiative, Henley noted.

Board members of the collaboration are determining long-term funding sources.

Henley said they also plan to continue growing the number of agencies involved in the initiative, and hope more private-sector agencies will consider joining the collaboration.

More information on My Care Community is available at linncounty.org.

Comments: (319) 368-8536; michaela.ramm@thegazette.com

My Care Community Members

Abbe Center for Community Mental Health

Area Ambulance Service

Area Substance Abuse Council

CarePro Health Services

Community Health Free Clinic

Mental Health/Disability Services of the East Central Region

Eastern Iowa Health Center

Foundation 2

Hawkeye Area Community Action Program (HACAP)

Heritage Area Agency on Aging

His Hands Free Medical Clinic

Horizons, A Family Service Alliance

Linn County Public Health

Mercy Medical Center

Metro Care Connection — Cedar Rapids Community School District

Tanager Place

UnityPoint Health-St. Luke’s Cedar Rapids

United Way of East Central Iowa

Waypoint Services

YMCA

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