Provider Story: Data Sharing to Assist Care Managers

Anwar Zoueihid  
Vice President Long Term Services & Supports, Partners in Care Foundation

Mission: Create a future of seamless and automated data exchange to support proactive and effective care coordination. 

Where We Were:

In the early 2000s, I worked as a care manager alongside social workers, community health workers, and nurses. The workload was hefty, managing a caseload of over 55 older adults with the added challenge of coordinating Medicaid waiver benefits for my clients. One particular case, Jennifer, stands out to me as an example of where real-time automated data exchange could have helped a patient receive necessary care more quickly. Jennifer had a complex medical history with frequent readmissions, often resulting in skilled nursing facility (SNF) placements. Jennifer was recently readmitted to the hospital when she was assigned to me, and it was my responsibility to ensure her safe transition back into the community and prevent further readmissions. 

It was a time of little to no data sharing and only manual care coordination efforts, making coordination difficult between medical and social care providers, health plans, and even her landlord. Questions loomed around unpaid rent and how to safely transition her from the SNF back home. Health plans wouldn’t talk to me about benefits or help coordinate Jennifer’s care, and because providers wouldn’t discuss Jennifer’s case by phone, I had to drive to the hospital and to the SNF to work with discharge planners and ensure a safe place for discharge. A less manual, arduous process could have helped her receive necessary care more quickly while helping me to be more effective in my role as a care manager.

Where We Are: 

While there’s been encouraging progress in data sharing, there is still much more work to be done. We’re in the era of “partial automation,” with some data exchange partnerships established, albeit often slow and inconsistent, sometimes resorting to outdated methods like fax. The discharge process has improved, being 28 days faster on average, but silos still exist, hindering effective collaboration.

Vision for the Future:

I can see a future where data exchange is fully automated to support patients like Jennifer so that home safety is ensured without any hitches or diversions. 

Proactive medical care is the norm, with care management teams identifying individuals at risk of hospitalization before it occurs. Real-time admission, discharge, and transfer (ADT) notifications flow to enable swift action. Health and social service providers have a single, easily accessible view of a patient’s full history. Real-time data feeds communicate important information across health care facilities to eliminate duplicative services and reduce the overall cost of care. 

In this world, the patients who need it most are helped safely and proactively so they may continue to live and thrive in their communities with support from care managers leveraging data sharing to effectively coordinate their care.


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