Improving Care Coordination through Information Sharing

Perspectives from Rosemary Veniegas, PhD, California Community Foundation, and Andrea Williams, MPA, Southside Coalition of Community Health Centers

Encouraging hospitals to work with community partners to develop shared protocols and better co-manage patients is a key strategy for building programs that support individuals with multiple chronic conditions and other complex needs. Through support from the California Community Foundation, Dignity Health California Hospital Medical Center and the Southside Coalition of Community Health Centers partnered to pilot a health information exchange system that allowed primary care providers to receive real-time notifications when one of their patients was registered in the emergency department or admitted to the hospital.

This effort was able to enhance care coordination for patients with chronic health conditions among the hospital and seven community clinics and helped reduce inpatient readmissions by 12 percent and emergency revisits by 57 percent for patients who were navigated to medical homes and assisted with visits. Since the program was implemented in 2016, more than 7,000 patients have been served. The Better Care Playbook recently spoke with Rosemary Veniegas, PhD, Senior Program Officer, Health, California Community Foundation, and Andrea Williams, MPA, Executive Director, Southside Coalition of Community Health Centers, to learn more about their health information exchange pilot.  



Q: What insights would you like to share about partnering on this pilot?

This idea was originally pitched by the community clinics in partnership with the hospital. Everyone had very aspirational and aggressive goals around patient outcomes, and that’s something we all kept in mind. As we talked about funding this grant, we built in enough time for planning and for the program to be implemented, especially knowing that it was a multi-organizational partnership. We were all very upfront about the challenges. What helped tremendously was that we had shared values around patience and trust. This alleviated some of the anxiety and concern when implementation challenges understandably arose.  

Q: How did you make the case for this work to leadership and other staff?

We started with a big question: How can this pilot address the volume of patients who have complex care needs? While the pilot wasn’t specifically emergency department focused, that’s what emerged. The hospital recognized that they were seeing a lot of patients with complex needs and wanted to better understand how to help them. They recognized that they needed additional support and better coordination.

Meanwhile, the clinics had patients who would show up without the clinic having any information on them. No discharge instructions, no detail on care provided in the hospital, no indication why they were discharged. Both sides recognized that to provide more coordinated care, they needed to share and transmit information. We tried to pair the hospital with local clinics in ways that were meaningful and mutually beneficial.

Q: What have you learned through this process that others may find helpful?

To be successful, efforts like this need to be funded at a sufficient level over an extended period. From the funder perspective, we went into this with an investment of $750,000 for three years. For us, this was a big change. Our grants were usually $50,000-100,000 for one year. But investing for a longer period enabled the program to plan properly and ultimately succeed.

On an implementation level making the connection between the hospital and clinics has been valuable and positively impacts how patients experience their care. Things like minimizing the number of people interacting with patients so we reduce confusion, talking to patients about their care, helping them schedule and get appointments patients benefit from this. 

Q: What is a result of this pilot that you are proud of?

The decline in inpatient readmissions is something to be proud of. At the start, 50 percent readmitted. Now it’s closer to 20 percent. It’s tremendous.