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By Athena Mandros

The big push in health and human services is to find a provider organization to take on the responsibility for comprehensive care coordination for consumers including some degree of financial risk for the results in terms of consumer outcomes and consumer health care spending. The role of this comprehensive care coordination organization goes by many names – medical home, health homes, specialty medical homes, behaviorally led health homes, totally accountable care organizations. But what they all share is that accountability for the total outcomes for a single consumer.


There is a lot of competition for this care coordination role – among primary care practices, federally qualified health centers, community mental health centers, addiction treatment programs, oncology practices, and more. Why? Because this is a new and highly desirable income stream, but also because the care coordination programs control consumer engagement, clinical decision support, consumer health data, and referrals. The strategic questions behind this development are two-fold – does your organization want to be in the care coordination role and, if so, is your organization ready to do this?

Dee Werline

That was the focus of the session, Building The Infrastructure & The Team To Manage Medical Homes & Health Homes, with OPEN MINDS Senior Associate Sharon Hicks and Dee Werline, Vice President of Administration at, Inc. at The 2016 OPEN MINDS Performance Management Institute session. They discussed just what it takes for organizations to succeed in implementing a health home or medical home model.

For the most comprehensive care coordination programs, there are a few key functional requirements that the organization needs to deliver: comprehensive care management; care coordination and health promotion; comprehensive transitional care from inpatient to other settings, including appropriate follow-up; individual and family support; referral to community and social support services; use of health information technology to link services.

The session focused on the core elements of readiness for organizations to assume this comprehensive care coordination role. These elements are:

  • Patient Centered Access
  • Team-based care
  • Population health management
  • Self-care support and community resources
  • Care coordination and transitions
  • Performance measurement and quality improvement


During the session, Ms. Werline talked about her experiencing in assessing the readiness of her organization to assume the role of a care coordination organization. is a community mental health center operating in 17 counties and serves about 26,500 patients a year. was able to identify a number of gaps in the readiness of their organization to implement health homes, including:

  1. Inadequate systems to collect data pertinent to the organization, compounded by the implementation of a brand new electronic health record.
  2. Poor performance measurement capacity to be able to continuously improve quality.
  3. Inadequate care coordination with a pressing need to identify patients that need care coordination, and train care managers in primary care and health promotion activities.

As a result of this readiness assessment, created new positions and revised old positions to “close the gaps.” For example, previously the IT director was in charge of day-to-day technology needs, but following the assessment, the organization hired a chief information officer to deal with the more complex data collection needed by the organization. Additionally they decided to hire a quality improvement director with a background in both behavioral and physical health to add the knowledge base needed to coordinate care for the whole person.

If you are looking to assess your care coordination readiness, remember – the key to this readiness assessment is to identify gaps in your organization and not “pat yourself on the back.” It’s better to assess yourself at 50% ready and make the necessary changes, than assess yourself at 80% ready and come up short. You have to create a culture where people are rewarded not for identifying someone’s weaknesses, but for making the organization better.

For more, check out: Health Home Gap Analysis In Four Slides, Core Set Of Health Care Quality Measures For Medicaid Health Home Programs, and Medical Home & Health Home Accreditation – What Are The Options? from the OPEN MINDS Industry Library. And, make sure to join us on June 9 for The 2016 OPEN MINDS Strategy & Innovation Institute session – When You’ve Seen One Health Home, You’ve Seen One Health Home: The Provider Perspective On Health Homes.

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