Evolving healthcare delivery models demand community care coordination. An array of providers including health, behavioral health, and social supports are collaborating to deliver whole-person care. As providers work together, a patient’s interaction across the continuum of providers is recorded and shared among all participants. The availability of this data helps medical providers see the whole spectrum of a patient’s needs and choose an appropriate treatment plan. Likewise, a community provider benefits from reviewing a patient’s health history prior to recommending a care plan that addresses their social needs. Improved patient wellbeing and reduced costs for providers results, as they are able to avoid costly, more intensive care settings such as emergency or institutional care.

A successful community care coordination model includes not only the capture and management of social determinant’s of health data collection but also the introduction of interoperability to support the sharing of that data among health and community providers. Value-based payment models increasingly impact care coordination—rewarding providers keeping people healthy. An integrated care coordination platform is the key to making this happen.

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