Coordination of Care

Community NeedFI-doctor

As part of the 2012 Roanoke Valley Community Health Needs Assessment, stakeholders and providers who participated in focus groups identified access to health and human services in the Roanoke Valley as the greatest resource that impacts the health of the community.

However, they noted a need for a centralized system for coordination of care to maximize the use of these resources. They cited health literacy as the second greatest barrier to care for their target populations and reported that those they serve:

  • Are unable to navigate the healthcare system;
  • Have limited understanding and compliance to treatments;
  • Have an overall lack of understanding of health;
  • Lack an understanding of existing resources;
  • Have poor communications with their healthcare provider.

In addition, Carilion Roanoke Memorial Hospital’s Emergency Department reported that solutions to an overburdened system begin with improving access to primary care through stronger care coordination with existing providers.

Healthy Roanoke Valley Goal and Program Strategy

Coordination of Care Goal: Improve the coordination of care and ensure access to available resources and services that address the healthcare needs of the community.

Coordination of Care Program Strategy: Define and implement a Centralized Care Coordination System that connects residents to resources available in the community and helps these residents enter and navigate through the system.

Expected Outcome

  • Increase the proportion of persons with a usual primary care provider.
  • Increase the proportion of persons with a specific source of ongoing care.

Action Team Initiatives

  • The Coordination of Care Action Team identified the Agency for Healthcare Research & Quality’s Community Pathways HUB as a best practice model for planning and implementing a Centralized Care Coordination System.
  • The Action Team has been working to define the steps for creating a HUB in the Roanoke Valley including the requirements for a lead agency, a sustainability plan for the program, benchmarks for accountability, and tools and documents needed for care coordination.
  • The first pathway developed is the “ED to PCP” Pathway designed to ensure that at-risk individuals who routinely use the Emergency Department for non-urgent services are redirected to a Primary Care Home. In addition, patient education is provided addressing the value of a primary care home, preventive services, and management of chronic conditions.
    • A pilot of this pathway was conducted by Project Access of the Roanoke Valley and Carilion Roanoke Memorial Hospital June 2014 to December 2014. Data analysis and evaluation of the pilot is currently underway.