The Advanced Metrics team, in collaboration with coLAB, performed a community needs assessment on behalf of the Lancaster Osteopathic Health Foundation (LOHF). That assessment identified strong opportunities for improvement in coordinated care between behavioral health and medical health providers in Lancaster County.
The result? The creation of NavWell. NavWell was conceptualized as a way to systemically capture data among the providers, and combining that process with a dramatically-improved environment for coordinated care. The goal: to improve and increase the number of successful referrals to behavioral health providers from primary care providers.
NavWell works by tracking all of the incoming shared information from enrolled providers in a patient’s coordinated care team. It provides the opportunity for evaluation and measurement of missed service opportunities. Patients – or their providers – have the option to complete assessments contained within NavWell that are automatically scored with symptom severity.
NavWell also has the ability for electronic referrals, referral outcome tracking and follow-up, with care-coordination being a significant part of the referral follow-up process. NavWell’s built-in capabilities provide for systems-oriented data gathering, which can measure the effectiveness of the referral process. Combined with integration of patient medical records, it can also perform a cross-analysis, taking a closer looking at the improvements in health outcomes against the quality of the referral follow-up.
The community needs assessment certainly made it clear: the current landscape for referral quality is poor. There is no standardized means to collect data for comparative analysis—whether you are looking at patient outcomes, patient group outcomes, quality measurements, provider quality, or best practices compliance. With NavWell, health outcomes are improved, health care costs are reduced, and best practices are introduced into provider-clinician relationships. Coordinated care can truly be achieved.
This data sharing also improves transparency, identifies larger population health trends within a given practice, and increases patient comfort, notably among patients who are managing
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