Connecting clinicians and community-based programs to improve health.
In 2016, HealtheConnections set out to improve the referral process by leveraging the power of the HIE and its large pool of participants, and created a mechanism for healthcare providers to make perinatal referrals to the Healthy Families Program for Onondaga County residents. Now, the organization is about to launch its expanded referral platform that provides healthcare professionals with the tools they need to refer patients to evidence-based community programs.
With funding from the New York State Department of Health under the Local IMPACT grant, HealtheConnections was able to expand supporting HIE architecture and begin referrals to the National Diabetes Prevention Program (NDPP) in seven Central New York counties. The success of these initiatives has led to the current expansion of the platform, increasing the number of counties covered by the service and adding three new evidence-based programs: Chronic Disease Self-Management, Diabetes Self-Management and Blood Pressure Self-Monitoring.
The benefits of the platform lie in the ease of choosing and making the referral, and opening a bi-directional channel for feedback. Using HealtheConnections’ extensive and diverse participant base and HIE infrastructure, it allows healthcare providers to select the community-based program best suited for the patient, complete an online referral form, and submit the form directly to the receiving organization via Direct Mail. The recipient organization can then begin working with the patient to obtain consent and use HealtheConnections’ Patient Lookup to view other medical information that may be vital to the patient’s improvement plan. The entire referral process is HIPAA-compliant and supports bi-directional communication between the provider and the community-based organization, thereby helping providers meet their value-based care delivery targets.
The platform has already generated positive attention from Central New York communities as well as other communities across the state and nationally. HealtheConnections was chosen to be a presenter at the National Diabetes Prevention Program conference hosted by the CDC in June to discuss the mechanics of the platform and benefits to the HIE community.
The vision and goals for the platform directly support the mission of improved care for all patients. HealtheConnections is motivated to continue growth in this area, expanding on current services and seeking out innovative approaches to improve health in our region and beyond.