By John Blair

Mallory has been a discharge coordinator at a local Louisville hospital for the last three years. She’s good at her job, loves the people she meets, and appreciates the engagement she creates between staff and patients. She knows the service she provides is valuable — the problem is once a patient leaves her office, she knows many of them do not take advantage of the suggestions she gives or the programs that the community offers that could help keep them from returning in the future.

Coordinating the departure of patients leaves her feeling a bit empty.  How does she know these patients are getting the wrap-around care they need?  The woman she discharged yesterday desperately needs dietary support to manage her diabetes but blushed and looked down when Mallory asked if there was food in her fridge.  She wonders about the older gentleman last week who said that he was going to ask his nephew to help him get to the pharmacy to get his prescriptions filled.

Sure, she can give them a business card and a name, but once they move beyond the exit door, how can she be certain they’re getting the help they need from other providers?

There are hundreds of Mallorys across Louisville whose struggles could be a thing of the past thanks to a new program called United Community.

Seamless Referrals

United Community is a community-wide initiative to deploy an innovative shared technology platform to initiate and close referrals across many organizations.  It reduces barriers to access for citizens by streamlining navigation across the multitude of services offered by our health, education and human services sectors. The platform enables seamless referrals between agencies to meet a variety of essential needs.

United Community will be a robust community service coordination system that will improve the life outcomes of our most vulnerable children, individuals and families across Louisville by facilitating integrated, multi-dimensional support efficiently.

Essentially, if Mallory could electronically refer her patients to support services on the United Community platform and track whether her patient and the agency actually connected, she could be more certain the follow-up care they need would happen, preventing patients from falling through the cracks.

United Community is far from only targeting help for discharged patients. With partnerships across the health, education and human service sectors, United Community is also designed to address:

• Students who fall off track because of social needs and connect them and their families to the appropriate services.
• Individuals struggling with everything from addiction to job services are connected via a “warm handoff” to wraparound supports to help them overcome barriers to well-being.
• Caseworkers and physicians who need to share vital information about individuals’ needs, choices and living situations that could impact their ability to receive the care they need to become or stay healthy.
• Community leaders who want visibility into the number and types of services most needed and where gaps exist in available resources.

United Community has assembled an impressive group of “who’s who” committed to moving forward with implementation, including Metro United Way, Passport Health Plan, Kindred Healthcare, Norton Healthcare, Jefferson County Public Schools, 55,000 Degrees, Evolve502, Louisville Metro Government Department of Public Health and Department of Resilience & Community Services, Coalition for the Homeless, Dare to Care Foodbank, Louisville Primary Care Association, Family Health Centers, Centerstone, Goodwill, Catholic Charities, Jewish Family and Career Services, Family & Children’s Place, Americana, Neighborhood House, Kentuckiana Works and University of Louisville Commonwealth Institute.

Metro United Way, based in Louisville, is driving the United Community effort alongside leaders from Passport Health Plan, the Department of Public Health and Evolve 502.  Funding support for the initiative has come from generous investments by LG&E KU, The James Graham Brown Foundation, Jewish Heritage Fund for Excellence, Kindred Healthcare, Norton Healthcare, Passport Foundation and Health Plan, and the Community Foundation of Louisville among others.

“There are too many people who are negatively affected by social and economic factors that limit their overall well-being,” said Theresa Reno-Weber, president and CEO of Metro United Way. “United Community affords us the chance to address this reality and become known as a leading community that uses technology and collaboration to connect people with the services they need.  It’ll be easier for people to get what they need when they need it. United Community makes it easy to meet multiple needs of individuals and families across sectors, and ultimately track their experience to measurable outcomes.”

Passport Health Plan saw an opportunity to improve patients’ outcomes through this community-wide platform.

“The creation and implementation of United Community to share data between doctor’s offices, hospitals, schools and social service organizations at multiple touchpoints will streamline access, navigation and coordination of all available resources,” said Liz McKune, vice-president for Health Integration at Passport Health Plan. “This ‘no wrong door’ solution ensures those who need support are quickly referred and served, which will be a dramatic improvement over current care referral in our community.”

Reno-Weber points to results from other markets offering similar wrap-around supports that have yielded positive outcomes.

“Our technology partner, Unite Us, has experience connecting folks in this way in more than 50 markets across the country,” said Reno-Weber. “In a little over a year in Charlotte, N.C., they’ve seen a nearly 10-day decrease in the time it takes to make a successful client referral, and a 30-day decrease in the time it takes to close a referral. The results are phenomenal and the longer the platform is in place, the greater the efficiencies and the better the outcomes they’re seeing.”

All of this is good news for discharge nurses like Mallory, who will use the United Community platform and be able to see that her patients are getting the collaborative care they need.

United Community Goals

• Develop a single, connected, collaborative, community-wide system to coordinate care and services across sectors to address all social determinants impacting health and education with real-time data tracking and reporting.
• Measurably improve health, education and well-being outcomes by coordinating the delivery of health and social services among high needs children, individuals and families.
• Create a “no wrong door” system through which individuals are matched with appropriate services based on their unique needs across the health, education and social service sectors, including tracking of client outcomes after service referrals are made.

–John Blair is Chief Brand Officer at Metro United Way in Louisville, Ky.