In Los Angeles County, an Enhanced Care Manager (ECM) provider presented the DxF Community Design Studio with data sharing concerns impacting their ECM delivery to Medi-Cal members with complex health and social needs, including:

• Lack of detail in Admit, Transfer, and Discharge (ADT) notifications when their members are discharged from a hospital;
• Inconsistent methods of transitioning care from one provider to another, and;
• A disjointed, often manual process for sharing ECM Care Plans with Medi-Cal managed care plans and other provider organizations.

By utilizing a human-centered design approach, the team developed a use case around a fictitious woman in Los Angeles in need of support with chronic health conditions and imminent homelessness. The use case chronicles her journey from timely enrollment into ECM services to receiving coordinated benefits with corresponding quality care coordination all along the way. In addition to the ECM provider, the design process included a Qualified Health Information Organization (QHIO), Managed Care Plans (MCPs), and a hospital provider group. Having a diverse group of organizations allowed for productive dialogue and actionable recommendations.

Post Community Design Studio references include:

• Complete User Story that chronicles the care-journey for an individual that is eligible and engaged with an ECM provider. The User Story identifies every actor that is involved in the care-journey, documents system-level assumptions, and outlines data flow between and among organizations.
• Data Requirements with regulatory, legal and standards compliance considerations.
• Issues and Risks used to mitigate implementation planning.
• Synthetic Data for use case validation.

Sign up for the DxF Community Sandbox and access the full use case.