Health Care Access Now, or HCAN, is a Cincinnati nonprofit organization dedicated to addressing health disparities and poor health outcomes by building partnerships to improve access to quality healthcare for the under-resourced. We recently recognized HCAN and the YMCA of Greater Cincinnati as joint Gen-H Award winners, for teaming up to offer type 2 prediabetes prevention to low-income and minority patients. Among its programs are care coordination services, not only to improve health outcomes for those who may be pregnant or suffer from chronic disease, but to help clients avoid unnecessary emergency department (ED) visits by seeking more suitable care.

Not surprisingly, the result of this patient-focused approach is better health outcomes, a better experience of care for patients, and ultimately, lower overall costs of care – known as the healthcare Triple Aim. HCAN’s overarching goal is to connect patients with services related to medical and dental care, health insurance options, and other resources to ensure appropriate disease prevention, management, and treatment.

HCAN works with The Health Collaborative (THC) to achieve these goals around patient-centered care coordination by utilizing the hb/notify service. THC offers a line of products and services to bring all the pieces together for healthcare providers, payers, health systems, and community service providers to ensure they have the right health information in the right place, at the right time. Our technology-based service known as hb/notify delivers real-time notifications to care providers and community health workers (CHWs) directly into a patient’s electronic health record, whenever a hospital or ED encounter has occurred for an attributed patient.

Better health for clients, better efficiency for staff
Sarah Mills and Judith Warren of HCAN accept the 2017 Inspire Gen-H Award. Photo by Ron Alvey.

Sarah Mills and Judith Warren of HCAN accept the 2017 Inspire Gen-H Award. Photo by Ron Alvey.

We spoke with Sarah Mills, SW Ohio Hub Director at HCAN, about her experience with hb/notify and how it has affected the daily workflow for HCAN staff. “hb/notify helps us do our jobs better!” Mills shared. “When a notification about one of our clients arrives for an ED or hospital visit, we can intervene quickly and proactively think about how to avoid a similar episode next time.”

Using complex matching algorithms, hb/notify is able to monitor the hospital ecosystem for a HCAN patient’s activity. It quickly puts valuable information into a care coordinator’s or community health worker’s hands, to ensure proper care coordination and other proactive efforts are made to reduce hospital admissions in the future. This means better health outcomes for clients and more efficiency for staff.

“hb/notify also helps us with follow-up, because our clients may often have changes to their contact information such as address of residence, phone number, etc.,” Mills said. “With hb/notify we can track our patients better, in real-time, so we can fact-check and educate them on follow-up care.”

Before HCAN began utilizing hb/notify technology, there was typically a delay in receiving hospital and ED alerts since they had to be pulled manually by administrative staff each morning. Now when a CHW logs into the HCAN system, alerts are pushed directly to patient records to ensure immediate, appropriate action.

Mills concluded, “Many of our clients don’t have an existing support network, and it can be difficult to connect the dots when navigating the complex healthcare system on their own. hb/notify enables our CHWs to provide better, more proactive service to our clients by recognizing their needs early, and clients feel more supported in achieving their goals for better health.”