Enhanced Service Coordination

Author(s): RAND Corporation, HRSA HIV/AIDS Bureau (HAB)

Goals for This Chapter

This chapter is designed to help you:

  • define expectations for how providers will use the new client-level data accessed through the integrated system
  • specify the service coordination processes that providers will be expected to participate in based on the integrated data system
  • identify additional needs and opportunities to coordinate at the organizational and provider levels based on new shared data.

New Mechanisms of Service Coordination

Simply having access to new client data will not automatically improve coordination.

Providers need to understand how to interpret the new client data they are seeing and have a shared understanding of how all providers will respond to the new data. For example, if a provider at a housing agency sees that a client is out of care, what is the protocol for coordination with that client’s medical case manager? The housing provider has an opportunity to get a client back into care but needs to know whom to call and what the hand-off process should be. Not spending the time to specify and train providers on these mechanisms might lead to missed opportunities and inefficient use of your investment.

Questions to Ask Yourself

  • What supports do providers across our organizations need to develop a shared understanding with regard to service coordination processes and responsibilities? Do providers need joint trainings? Are there clear flow charts documenting new coordination pathways?
  • For each new client data element shared and new integrated data system functionality implemented, what are the service coordination mechanisms that should be enacted?
  • What is the best way to use the new integrated data system to improve communication between providers across our programs?
  • What are the frustrations our clients experience in having multiple providers? How can we use new information and new service coordination mechanisms to address these frustrations?

Lessons Learned

The following are some critical lessons learned by those at the performance sites implementing new service coordination mechanisms.

  • Providers from different programs have different roles, responsibilities, and resource constraints. Learning about the jobs of other providers is a critical first step to developing new coordination mechanisms. Include a discussion of terminology used because providers in different systems often use different language when referring to the same or similar things.
  • Coordination for existing joint/shared clients will likely look different from that for new clients. Think about what these new referral processes for joint clients should look like and what role each provider organization will have.
  • If providers would like to share additional client information to decrease time spent on conducting program eligibility, they should carefully review eligibility requirements across programs to find similarities and differences. Prompt entry of client information by all providers is especially important for the eligibility process.

Opportunities to Coordinate at the Organizational Level

It is quite possible that your partnering organizations will not have established close relationships with each other prior to the project. However, improving service coordination at the provider level cannot happen efficiently without organizational coordination and information-sharing.

Questions to Ask Yourself

  • How can we work better with partnering organizations offline (i.e., outside of the shared system) to ensure success of ongoing client data-sharing?
  • How can we best support our providers and encourage them to work more closely with their counterparts at partnering organizations?

Lessons Learned

The following are some critical lessons learned by those at the performance sites about opportunities to coordinate at the organizational and provider levels.

  • Establishing regular organizational communication (e.g., through standing calls or meetings) is vital and can help ensure that partnering organizations have a shared understanding and can then communicate the same messages to their provider staff and use the same processes to translate new information into better client services.
  • Joint trainings are critical opportunities to bring providers from different organizations together to build relationships, develop a shared understanding of roles and responsibilities, and generate solutions to shared challenges.
  • Ensuring that providers have time and support for provider-initiated meetings and a shared set of client information from which to work can improve coordination efforts.