Michiana Health Information Exchange

Waldo A. Mikels-Carrasco, Director of Population Health Research & Development, Michiana Health Information Exchange.  Waldo discusses the development of an HIE-driven solution that uses clinical and psychosocial data integration to extend beyond current operational models for avoiding readmissions of Medicare Shared Savings Plan Accountable Care Organizations (MSSP ACO) and Bundled Payments for Care Improvement (BCPI) patients. Triggering off an initial alert to the hospital that a dually eligible (Medicaid/Medicare) member has entered their system, care coordination staff screen patients for social needs that could potentially present post-discharge barriers, resulting in community-based case management to provide coordination of service referrals and reduce patient readmissions within 30 or 90 days.