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Developing healthier communities through comprehensive care plans

By Andy Pitman, Director, Health and Human Services Solutions, Microsoft on March 22, 2018

Filed under Health & Human Services

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Before Jim Calanni joined Microsoft partner Eccovia Solutions, he was chief technology officer for the Colorado Springs-based Community Health Partnership (CHP), which managed the care of over 180,000 members in Region 7 of Colorado’s Accountable Care Collaborative. Jim led the design and development of a comprehensive, data-sharing infrastructure linking primary care, mental health and social services providers across a region, in this case, Southern Colorado.

Jim recently shared his wealth of expertise in an Eccovia Solutions webinar to help other areas create their own comprehensive care plans for healthier individuals and families. Jim and his CHP colleagues used technology from Eccovia Solutions and Microsoft to develop a true community care program as opposed to the more typical solution revolving around historical charting of past medical issues. “The paradigm shift that I saw when I took my previous position at the Community Health Partnership was moving from disease treatment to a prevention model,” he explained. “How do we get in front of the problem of chronic conditions or social-economic factors that contribute to reduced health for folks?”

The CHP team first looked at healthcare costs and where money was being spent. They found that most dollars were going toward pharmaceuticals, with very little spent on preventing medical problems. To reverse that trend, Jim said, “we wanted to build an infrastructure that was capable of collecting data at the ground level and then moving that data into an organized fashion, coalescing it into information, and then moving that information into knowledge by beginning to apply some data analytics and science to it.” The outcome: getting enhanced information into the hands of the broad, coordinated health community to have a greater impact on the public becoming healthier through preventive measures.

CHP used Eccovia Solutions’ ClientTrack Care Coordination platform, powered by the trusted Microsoft Azure Government cloud, to manage patient care with multiple agencies across the care continuum. Over the past five years, their innovative community care program revolutionized the Medicaid delivery system through a collaboration of local health providers. The coordinated, community-based strategy also optimized the outcomes and care of high-risk populations, such as the homeless, children in foster care and those who overutilize emergency departments. 

For communities considering developing a similar care coordination framework that enables a comprehensive care plan, Jim suggests asking these six questions:

  • “Why are you trying to do this? It’s the most important thing to start with.”
  • “Who controls the data you’re trying to get? It can be a very disruptive and complicated process … to get access to data.”
  • “How are you going to impact what you’re trying to do? Do you have a leader in the community who’s going to drive this?”
  • “What are you going to do with the information … how are you going to dispense it throughout the community?”
  • “When do you want to do this? … You’re going to have to overcome the legal considerations of how you gather such data and very serious privacy considerations on how you distribute the data.”
  • “Where are you placing the data? I personally have worked very closely with Microsoft’s Azure platform … a secure environment and Microsoft is leading the industry with machine learning … it’s an all-encompassing data environment.”

Jim called the “icing on the cake” of his Colorado experience the ClientTrack tool, which provides the flexible interface for rules-based sharing of data with the coordinated health community—hospitals, medical professionals, health and human services providers, nonprofits and more. It’s exciting that Jim is now sharing his experience and insights with more U.S. communities interested in pursuing a comprehensive health plan. To learn more, please see:

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