Lincoln County Community Care Coordination
This project will focus on patients and families who are emergency department high utilizers by developing a care team that includes primary care, substance abuse counseling, a county jail diversion team, and socioeconomic resources. Currently, the Lincoln County health system consists of four clinics that each have separate records and processes. This project will explore health care communication tools that will allow the clinics to exchange information among themselves and with social resources. Outcomes include enhanced communication and collaboration between the clinics and other resources, expanded care coordination with the ability to provide warm patient handoffs through patient care teams, improved population health, decreased readmissions, appropriate emergency department utilization, and lower health care costs.