How Egyptian Health Department leverages data to strengthen care coordination for at-risk kids

The 3M Health Policy Executive webinar series highlights our clients’ efforts to advance care outcomes and equity. In October, we were joined by Teresa Pickering, chief information officer (CIO) of Egyptian Health Department, which provides public and mental health services in southern Illinois. Teresa unpacked her organization’s participation in the Centers for Medicare & Medicaid Services (CMS) Innovation Center’s Integrated Care for Kids (InCK) model, which focuses on identifying kids who are at risk for physical and behavioral health issues, providing early intervention and strengthening care coordination. This blog post offers key takeaways from the webinar. 

Listening to clients share their stories is always a highlight of my role. As Teresa talked about Egyptian Health Department’s successes with InCK, three things really stuck out to me. 

Capturing the patient narrative is complex. 

Egyptian Health Department started its InCK initiative where many value-based programs begin: social determinants of health (SDoH) screening. With 11,000 children and adolescents on Medicaid within the service population, the Egyptian Health Department team rallied to collect this information by phone or face to face. It quickly became apparent that the full story isn’t always captured by self-reporting, though – patients and their caregivers may be unfamiliar with clinical jargon, may not understand why a physician needs specific information or may not want to share for personal reasons.

To augment the SDoH screeners and fill in gaps where possible, Egyptian Health Department turned to technology and implemented 3M risk grouping analytics to validate complexity and authenticity of the patient narrative using historical claims data. Doing so uncovered risk profiles that would have otherwise gone under the radar and helped Egyptian Health Department risk adjust its InCK population and identify at-risk patients.  

Novel data yields novel insights that are best addressed through community collaboration. 

The Egyptian Health Department discovered that the needs of its InCK population ran the gamut from food deserts to housing to a lack of access to laundry facilities. This information enabled the Egyptian Heath Department to bring forward creative solutions to address these issues, including partnering with community organizations to offer a weekly free laundry night and providing wellness coaches who help educate caregivers about complex and chronic medical conditions like asthma and diabetes. In addition, the Egyptian Health Department opened an integrated hub (iHub) – a facility that serves as a single point of contact for patients to get connected with resources and services that address SDoH. 

Along with supporting overall health and well-being, another one of InCK’s goals is to reduce unnecessary ED visits. By applying technology and analytics to this area, the Egyptian Health Department determined that approximately 37 percent of its ED visits were potentially preventable. This prompted the Egyptian Health Department to partner with urgent care facilities to operate on Saturdays in order to mitigate unnecessary ED visits by increasing access to other care options. Education is also important to break the cycle of parents bringing their children to the ED for care because that’s what their parents did for them.  

New care models must continue to strive for holistic health. 

CMS, the Egyptian Health Department and the seven other recipients of the InCK demonstration award are making great strides to deliver better health outcomes. More work needs to be done to expand the scope – something which Egyptian Health Department is already tackling head on by iterating on lessons learned from InCK and bringing similar models to their adult populations. 

Sharing best practices and key learnings from pilot initiatives like InCK will continue to be important as we create a health care system that focuses on the whole health of the person, not just what brings them through the door. 

A big thanks to both Teresa and Egyptian Health Department for sharing their story – and more importantly, for the critical work they’re doing on a daily basis in their community. 

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Clark Cameron is director of payer commercialization for 3M Health Information Systems.