Health

Linn County Public Health initiative signs up 5,200 patients in first 6 months

My Care Community shares information among agencies to help with needs such as transportation, food, utility bills

Pramod Dwivedi, Linn County Public Health director, speaks at a news conference in April in Cedar Rapids. At the news conference, Linn County Public Health announced an effort to share data among agencies, streamline patient referrals and improve community health outcomes. Six months later, Dwivedi says 23 agencies now are involved in the project, which aims “to improve not just the health, but also social well-being for people.” (Michaela Ramm/The Gazette)
Pramod Dwivedi, Linn County Public Health director, speaks at a news conference in April in Cedar Rapids. At the news conference, Linn County Public Health announced an effort to share data among agencies, streamline patient referrals and improve community health outcomes. Six months later, Dwivedi says 23 agencies now are involved in the project, which aims “to improve not just the health, but also social well-being for people.” (Michaela Ramm/The Gazette)

Background

CEDAR RAPIDS — In April, Linn County officials launched a new initiative to streamline patient access to economic and social resources that can improve their overall health.

Through this partnership, called My Care Community, several health care providers and not-for-profit agencies share patient information through an electronic system compliant with federal privacy laws.

This creates a direct referral process to other services, officials explained at a news conference earlier this year. That means a health care provider can direct a low-income patient to an agency that can provide transportation services to ensure they never miss an appointment, for example.

By using the electronic referral system — called TAVConnect — it reduces client burden and allows providers to know whether patients are accessing needed services.

The effort was driven by Linn County Public Health, which was awarded a $250,000 grant over three years from the federal Centers for Medicare and Medicaid Services to create My Care Community.

“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 in April.

What’s Happened Since

In the first six or so months of the effort, preliminary data shows nearly 11,000 identified needs among clients that range from employment to housing to child care to food.

So far, nearly 5,200 unique clients within the system have signed a release of information, which allows the agencies to share patient information with one another.

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Among those clients, there have been about 900 referrals between agencies in the partnership. Dwivedi said the top need identified based on referrals was income support and employment, followed by education and aid for utilities payments.

However, most clients were referred to services relating to food insecurity, which tells officials plenty of resources are available for people with that need, Dwivedi said.

At the same time, officials are hopeful the data can help identify where gaps in services exist.

“We are fulfilling those needs with regard to food insecurity, but what about education? What about utilities?” Dwivedi said.

About 1,000 instances were identified in which the need was aid with paying for utilities, but the partnership has been able to make only 28 referrals.

“So there is a huge gap,” Dwivedi said. “We want to fill those gaps so that people are able to address their needs and we as a community are able to help them address those needs.”

But so far, a challenge facing My Care Community is raising awareness among people who could benefit from the resource.

Three more agencies also have joined the partnership, bringing the total number of parties involved to 23.

My Care Community is a self-sustaining initiative, thanks to the funding each of the participating agencies contributes to the partnership. Certain agencies also make up a steering committee that governs the initiative, and Linn County Public Health serves as the fiscal agent.

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“All of these different agencies were working in their own territory, in their own silos,” Dwivedi said. “But with this partnership, we have created this very robust partnership where people are now collectively looking at the issues and trying to address the problem areas in order to improve not just the health, but also social well-being for people.”

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

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