Health and social care integration: what does it look like at the local level?


Providing effective wraparound care for older adults requires close coordination and data exchange between health care entities and social care providers. So-called ‘integrated care’ has become the call to action for many looking to improve care and well-being. The ‘how’ of integrated care, however, can feel vague or out of reach. In particular, investing in the technology infrastructure required to seamlessly integrate data between health care entities and social care providers can feel daunting, particularly for those outside large metro areas where technology and broadband access can be limited. In this article, hear from both the hospital and the social sector side of a partnership and draw inspiration from their determination to improve care for older adults in their frontier county.


Coming together in San Juan County, Utah 

San Juan County is a rural, frontier county in southeastern Utah, home to just over 14,000 residents. It is the largest county in the state by land mass with the smallest population, reflecting the rural nature of the county. Blue Mountain Hospital is a critical access hospital providing comprehensive healthcare services to the residents of San Juan County and the surrounding areas. Meanwhile, San Juan County Area Agency on Aging (AAA) provides a wide range of non-medical social services to older adults in the county. 

Sulane Knight, Director of Nursing at Blue Mountain Hospital, describes the state of affairs in the years prior to its partnership with San Juan County AAA, “We didn’t know about the resources in the community, and our nurses were stressed about helping people manage their way back from the hospital.” Challenges in the county extended from many of their residents having no running water or electricity, and many parts of the county with no cell phone coverage. If a patient didn’t have a wheelchair ramp at home, they wouldn’t be able to go home and there was little hope of finding a contractor to build one. 

Once she connected with Tammy Gallegos, Director of the San Juan County AAA, they began to connect the dots. Gallegos describes a shared vision that brought them both to the table. “Our goal was having better outcomes for our elders. We have so many services that the hospital didn’t know about, and the hospital had services we didn’t know about, and we wanted an opportunity for all of us to figure out what we do and how best to serve people.” 

There were business advantages too. Hospitals are required by the government to conduct discharge planning, the process of preparing for patients’ anticipated needs once they leave the hospital. Furthermore, hospitals are required to track readmission rates, when patients are readmitted back to the hospital following a hospitalization event. High readmission rates may impact a hospital’s reimbursements or incur penalties. By working in partnership with their local AAA, Blue Mountain Hospital could better ensure their patients went home with the resources they needed and avoid conditions that could lead to an unnecessary readmission. 

What did it mean to ‘integrate’

Integration between Blue Mountain Hospital and San Juan County AAA boiled down to data and workflow decisions. Data: what information gets shared and how. Workflow: at what point do patients get introduced to each provider, how, and who’s responsible. 

Gallegos from San Juan County AAA knew it was imperative to streamline the collection and sharing of data because it would mean a better patient experience. “It’s frustrating for the people we’re serving when they are giving information multiple times between the hospital and other providers like us.” 

Rather than have both parties collect what could be the same information twice, the collaboration introduced a simple referral form that hospital discharge planners used to send new patients to San Juan County AAA. From there, AAA case managers could conduct a more thorough intake to assess social service needs and recommend resources and programs. Any information collected from the hospital discharge planner is saved and shared with case managers so they have background and context. 

The group learned an important lesson early on about timing. The crucial time to start the referral process was not at the time of discharge, as originally planned. Instead, it was best to fill out the referral form on ‘admit’ - at the point when patients are admitted and there was time to discuss while patients were in the hospital. This changed the workflow and training to involve nurses at the outset who would then bring in discharge planners during a patient’s hospital stay. 

Hospital staff and AAA staff formed a single project team to meet on a bi-weekly basis to discuss such learnings and make changes as they went. Gallegos became the project point person and reported monthly to the funder. This structure of regularly recurring meetings helped ensure strong communication and sharing of information that kept the project moving forward. 


If your organization is exploring integrations with healthcare, check out these resources for funding and technical assistance: