Within a CIE, network partners commit to redefining a patient/client thinking beyond their individual programs and services.
Network partners are willing to re-engineer their business processes to better connect individuals to services and share new levels of information necessary for collective impact to address systemic needs and realize a shared vision for a healthier community.
Partners contribute to a CIE in different ways based on their organizational capacity and role within the community.
They also share challenges and best practices, inform policy decisions, champion expansion of the network, and contribute to the ongoing development of the technology platform.
CIE presents a holistic view of a person’s needs through a series of screenings and assessments identifying the nature and severity of needs across 14 domains. The assessments feed into a CIE Risk Rating Scale measuring a person’s immediacy of need, knowledge and utilization of resources, and barriers and supports. Risk Rating Scale score ranges from crisis to thriving in each domain.
CIE enables communities to shift away from a reactive approach to providing care and enable partners to integrate data from multiple sources and make bi-directional referrals to create a longitudinal record that promotes a proactive, holistic, person-centered system of care.
A CIE facilitates community care planning by offering tools built within the technology that allows agencies to share individual demographic information, status changes, and care team information, and to contribute to the community-wide care plans. Partners can communicate with each other and receive notifications and alerts of significant events. For example, when an ambulance is called, care team members (network partners) are notified so that they can proactively anticipate individuals’ needs and make referrals.
Other features of the CIE technology platform are a resource database and bi-directional closed loop referrals. The resource database enables providers to efficiently match individuals with appropriate care providers based on their needs. Bi-directional information sharing allows providers to accept and return referrals and share data about program enrollment and outcomes.