Session Description
This session explores how care teams can strengthen coordination and patient engagement while advancing culturally responsive practices.
Participants will learn to integrate behavioral health into wholeperson care models, address social drivers of health, and foster care relationships rooted in respect, trust, and equity.
Emphasis will be placed on aligning care strategies with members’ lived experiences and health goals, especially in underserved or historically marginalized communities.
Agenda
Welcome and Overview
Understanding the Data Landscape
Setting the stage: Why data matters in Tailored Care Management
Types of data sources and how they inform services and supports
Making Meaning from Data
Trends, standardization, and visualization strategies
Driving Performance with Data
Identifying care gaps, improving engagement, and risk stratification
Quality Improvement in Action
Practical steps to align data with cost, quality, and outcomes
Bringing It All Together
Q&A and Discussion
Takeaways and strategies for sustainable data-driven care
Recap from Protecting Data, Privacy & Compliance Webinar
Protecting health information builds trust and is essential to effective care coordination.
What We Covered:
• HIPAA and NC confidentiality rules
• Identifying PHI and safeguarding it in daily operations
• Phishing, device security, and multi-factor authentication
• Data governance frameworks and breach response
• Ethical and responsible use ofAI in behavioral health and I/DD services
Key Takeaway: Strong data protections are the foundation for using data confidently to improve outcomes.
Looking Ahead: Today, we build on that foundation to explore how to use data effectively to drive quality care and meet performance goals.
Reminder from Previous Webinar: Privacy, Quality, and Trust
“If we lose people’s trust by failing to protect their health information, we lose the opportunity to improve health outcomes.”
— Dr. David Blumenthal, former National Coordinator for Health IT (ONC)
Affects Health Outcomes?
It takes data and action to move from “sick care” to improving population health outcomes
www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html
https://www.cdc.gov/mmwr/volumes/73/wr/mm7331a1.html
“The problem in our age is not the lack of data, but the lack of understanding what to do with it.”
– Peter Drucker
Meaning
Wisdom
Knowledge
Information
Data Value
Centralize and Standardize Data Collection Across Programs
● Without standardized and centralized data, it's difficult to track outcomes, measure progress, or run quality improvement reports.
From Firehose to Insight
• Under the HITECH Act, approximately $30 billion was designated across the US to incentivize providers to adopt and effectively utilize certified EHR technology (20092016)
• For example, PCP use rates rose from ~10% to over 86%
• HCBS providers were largely excluded
• Technology doesn’t improve outcomes alone:
What “Data Sources” Exist?
Claims & Utilization
• Provider Claims
• Highly structured, standardized (ICD10, CPT/HCPCS) for trend analysis.
Pharmacy
• Pharmacy Claims
• Structured and validated through PBMs; fills and adherence for med management.
Hospital & ED Admissions, Discharges, Transfers
• RHIO/HIE ADT Alerts
• Detecting transitions of care and intervening on avoidable hospital use.
Social Determinants of Health
• Care Manager Entry
• Non-medical drivers (housing, food, transportation); not always consistent.
Member-Reported Data
• Care Managers / Members
• Self-reported; useful for understanding preferences, symptoms, and satisfaction but variable in accuracy.
Care Management
• Care Manager Entry
• Includes assessments and care plans; supports risk stratification and intervention planning.
Provider Records
• Providers (via EHR)
• Rich clinical detail including labs, diagnoses, assessments and notes; varies from provider to provider.
Data Source Considerations
Data
Spreadsheets (e.g., Excel)
Survey Platforms (e.g., Qualtrics, SurveyMonkey)
SharePoint / Internal Portals
Standalone
Databases
Access, SQL)
External Dashboards (Tailored Plans/CIN)
Individualstoriesmatter—buttrendsreveal whatpoliciesandinterventionsaretruly working
Cost, Quality, Complexity in IDD, TBI, and Behavioral Health Cohorts
• Have higher healthcare costs (MedPAC, 2008; Better Medicare Alliance, 2017)
• 115% of Medicare FFS, 4x that of non-dual Medicare beneficiaries
• Higher rates of chronic conditions (KFF, 2023)
• 65% have 3+ chronic conditions compared to 35% of general Medicare
• Lower hospital and ED utilization because of care coordination
• (MACPAC, 2019; Commonwealth Fund, 2020
• Preventive gaps persist in HEDIS measures (KFF, 2023)
• Measures like flu vaccine and cancer screening often 15-20% lower
Data Shared from Tailored Plans to CMAs and AMH+s
Beneficiary Assignment – Member demographics and eligibility info
Pharmacy Lock-In – Flags members with controlled substance restrictions
Claims/Encounter Data – Physical, behavioral, and pharmacy claims
Acuity & Risk Stratification – Member risk tiers and stratification methods
Quality Performance – Provider-level quality measure results
Additional Data (TBD) – Care plans, ADT alerts, and clinical history
https://medicaid.ncdhhs.gov/tailored-care-management/tailored-care-management-data-specifications-guidance
Claims and Encounter Data
•Chronic Conditions Identification:
Use diagnosis codes in claims to flag members with conditions like diabetes, SUD, or SMI, and assign risk levels (low, rising, high) to prioritize proactive care and prevent costly complications.
•Recent Service Utilization:
Monitor gaps in care by calculating days since the last TCM, PCP, BH, or ED visit—triggering alerts for re-engagement and reducing avoidable emergency or inpatient use.
•Encounter Frequency Analysis:
Track encounter volume by service type (e.g., ED, BH, rehab) over time and compare across populations to identify high utilizers, assess care plan effectiveness, and support targeted interventions.
Provider Person Served
Payer Information
Date(s) of Service
Procedure Codes (CPT/HCPCS)
Diagnosis Codes (ICD-10)
Place of Service (POS) Code
Charge Amounts
Units of Service
Population Health & Outcomes
"The health outcomes of a group of individuals, including the distribution of such outcomes within the group."
— Kindig & Stoddart (2003)
1. Outcomes: Morbidity, mortality, quality of life.
2. Determinants: Social, economic, environmental, behavioral, and medical factors.
3. Interventions: Policies and programs aimed at prevention, care coordination, and addressing social determinants.
Engagement & Continuity of Care
• Who has or hasn’t had a PCP visit in the past 12 months?
• Who has or hasn’t seen their behavioral health provider in the past 90 days?
• Who hasn’t had their preventative screenings?
• Gaps in care increase risk for hospitalization, crisis events, and relapse
• We can tell with claims, encounter history, and appointment systems
Protecting Coverage: Using Data and Engagement to Support Medicaid Eligibility
New Medicaid policies will include work and reporting requirements for beneficiaries. Individuals who do not meet these requirements, or do not report compliance, risk losing coverage, even if they remain eligible.
People with I/DD, behavioral health needs, or complex life circumstances may miss notices or misunderstand new rules. Loss of coverage can lead to interrupted care, medication gaps, and increased crisis events.
How Providers and Care Managers Can Help:
• Use available data (e.g., missed appointments, outdated contact info, prior benefit disruptions) to flag individuals at risk
• Proactively engage members to check eligibility status and encourage timely reporting or exemptions
• Coordinate with enrollment specialists or navigators to support recertification and work requirement reporting
• Document barriers and follow up consistently
Preventing benefit loss helps maintain access to services, ensures continuity of care, and reduces downstream costs from avoidable ED visits or hospitalizations.
Baxley, J. (2025, June 18). By the numbers: Medicaid work requirement could strip coverage from thousands in NC. North Carolina Health News.
https://www.northcarolinahealthnews.org/2025/06/18/workrequirement-numbers-for-nc/
Risk Stratification
• Which members are rising-risk based on:
• New diagnoses
• Increased ED use
• Untreated conditions?
• Preventative supports and early interventions are highly effective in avoiding high-cost events.
• We can tell with claims, diagnosis codes, assessments, and ED/hospital data
Closing Gaps & Monitoring Medication Adherence
Consequences of Non-adherence:
• 5x Increased Risk of Relapse and Hospitalization
• Longer Hospital Stays
• Higher Suicide Rate
• Reduced Quality of Social and Occupational Functioning
• Increased Costs
El Abdellati, K., De Picker, L., & Morrens, M. (2020). Antipsychotic treatment failure: A systematic review on risk factors and interventions for treatment adherence in psychosis. Frontiers in Neuroscience, 14, Article 531763. https://doi.org/10.3389/fnins.2020.531763
• Are members filling their antipsychotic prescriptions regularly?
• Non-adherence increases relapse, hospitalization, and mortality risk.
• We can tell with pharmacy claims, refill history, and assessments.
Crisis Utilization and Avoidable Hospital Use
• Who is using the ED or being hospitalized frequently?
• This could be an opportunity for wraparound services.
“Preventable ED visits cost the U.S. healthcare system over $30 billion annually— most of which could be avoided with better access to timely outpatient care.”
• We can tell with ED claims, ADT feeds, incident reports.
— Centers for Medicare & Medicaid Services (CMS)
Integrating Behavioral Health: Moving Toward Whole-Person, Data-Driven Care
The Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration (SAMHSA-HRSA) framework outlines a path from basic coordination to full system-level integration. To move toward whole-person, population-based care, providers can use data, such as claims, screenings, and risk indicators to:
• Identify behavioral health needs through structured outreach and screening
• Coordinate care team huddles using alerts about missed appointments or crises
• Develop shared care plans that align physical and behavioral health care
• Support system-level integration through aligned workflows and data systems
• This model encourages moving beyond co-location to collaborative strategies that improve outcomes for diverse and underserved populations.
Social Determinants of Health (SDOH)
• Who lacks stable housing, food security, transportation, or caregiver adequacy?
• SDOH drive health outcomes more than clinical care alone.
• We can tell with assessments, surveys, case manager reports, and sometimes details in NCCARE360.
www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html
Training and Quality Improvement
● Empowering People with Data: Building Skills, Systems, and a Culture of Continuous Improvement
Building a Data Driven QI Culture
Establish metrics that you have the data to track (e.g., engagement rates, ED visits, follow-up after hospitalization)
Use data to monitor trends and spot gaps (monthly or quarterly reports or dashboards)
Regular team review of quality reports tied to performance goals
Celebrate wins and learn from data-related challenges
Share examples of how you document and share outcomes, individually and at a population level
Aligning Quality with Cost
• Data infrastructure allows the controls and dashboards to identify outliers, spikes, and ensure operational consistency for each cohort of members
• Tools to track utilization, experience, and inform better outcomes.
Audit and Alerting Practices
Train staff at all levels to understand, question, and act on data
— not just IT staff, but Care Managers, Care Manager Extenders, and DSPs.
Establish CQI teams or huddles that regularly use data dashboards to guide changes.
Tie technology investments (like training time, dashboards, alerts, or AI tools) to practical decision points.
Bringing it all together
Use Data with Purpose: Move beyond data collection to data action—track trends, close gaps, and inform decisions that improve health outcomes.
Train for Impact: Ensure all staff understand their data responsibilities and how their actions contribute to cost, quality, and equity.
Drive Whole-Person Care: Align data strategy with person-centered goals—addressing physical, behavioral, and social health needs in tandem.
Protect Trust: Maintain HIPAA-aligned safeguards, role-based access, and audit practices to protect PHI while enabling responsible data use.
Empower Through Technology: Use EHRs, dashboards, and responsible AI to streamline workflows and surface meaningful insights.
Invest in Quality: Build a culture of continuous quality improvement using standardized metrics, feedback loops, and real-time reporting.