Effective team based care requires a high level of collaboration between all members of the care team, including patients and their families.  Health care teams are generally able to communicate best when they are all practicing within a similar health system.  Challenges arise when providers, hospitals and facilities, and other members of the care team are not linked through common health records or other health information exchanges.  Similar challenges to coordinating care exist when there are providers from across physical and behavioral health systems involved in the care team. 

The coordination of care is exponentially more complicated when community and social systems of care are also members of the care team.  And, all too often patients and their families are excluded from full and transparent participation in integrated care teams.

Integration of Social Care Services Using Technology

The full integration of care involves providers who address the physical, behavioral, and social determinants of health.  In order for care teams to coordinate services across these provider systems, technology solutions are required. InfoMC provides an integrated care management platform (Incedo) for team based care. This resource supports all care team members, care coordination and management organizations, and patients and families (or care plan members) to develop and implement person-centered care plans.

Communication Network for Social Workers

Too often, community and social service providers are excluded from care team inclusion since they operate outside of traditional health care communication networks.  These social care providers address and mitigate significant determinants of health. Social care is defined by a National Academy of Science, Engineering, and Medicine report as “Activities that address health-related social risk factors and needs.”  They also identify five key activities that support the integration of social care into health services.  These include:

• Awareness – Activities that identify the assets and social risks of patients and covered populations
• Adjustment – Activities that support changing health care services to accommodate social obstacles and barriers to well-being
• Assistance – Activities that diminish social risks through actions that connects patients with appropriate social care resources
• Alignment – Activities taken by health systems to better understand existing social care assets in communities and organize and invest in them to promote positive health outcomes
• Advocacy – Activities that promote partnerships between health systems and social care organizations to develop assets and promote policies that address health and social needs

Providing Care Plans for Social Work

Incedo provides fully integrated Care Management capabilities that support auto-generated care plans including physical health, behavioral health, and social care.  These care plans enable high-quality, whole-person care coordination. Incedo Care Plans offer a seamless approach to coordinating the patient’s needed services and supports, and provided in the most integrated and cost effective way possible which enables a comprehensive quality approach across the continuum of care. 

Incedo functionality supports the ability of care teams to:

• Actively engage the individual in their plan of care
• Effectively communicate with providers and other care team members
• Collaborate with non-clinical providers such as community resources
• Coordinate and process referrals for medical, behavioral and community-based services
• Easily exchange information with providers (physician and non-physician, physical, community and behavioral health) via real-time, online applications
• Enable care managers, members and their families/caregivers, and providers to access information anytime, anywhere

Real-Time Coordination Care Sector

The Incedo Care Management solution also includes a Care Team Portal which allows care team members, patients and caregivers, care managers, providers, and community stakeholders the ability to collaborate and coordinate care in real time. The Portal gives care team members access to critical health information including a complete view of a patient’s clinical history across the continuum of care.  

This supports proactive engagement and participation in the member’s plan of care, and provides the ability to:

• Access the member’s care plan
• Complete evidence-based assessments
• Communicate in real-time
• Monitor care plan barriers and progress
• Add or update concerns, interventions and goals
• Send messages and reminders
• Track measures and outcomes

Social Care Organizations Assessment

Incedo Promotes efficient care coordination with customizable rules-driven workflows; automated assessments, tasks, and actions; and, facilitates timely data sharing and effective communication among all care team members.  This enables improved access to care in the most appropriate setting, and fosters improved health outcomes and well-being.