Information is Power: Mental and Behavioral Health Patient Attribution for Continuity of Care

Objective: The pediatric mental and behavioral health (MBH) health crisis is a public health imperative. Identification and management of MBH crosses primary care, community mental health centers (CMHCs), and hospital systems. To deliver the best outcomes, active collaboration and coordination of care is required. However, coordinated approaches are hampered by data silos resulting from lack of parity between physical and MBH, overly restrictive privacy policies, and technical barriers arising from disparate electronic health records (EHRs) across systems. This proof-of-concept provides information on the development and initial implementation of one model as a blueprint for other systems seeking to improve continuity of care. Methods: With cross-system collaborators, the population behavioral health leadership team at a large pediatric hospital advanced solutions to break down data silos via a MBH patient attribution strategy. Elements of this build included developing the value proposition, navigating legal requirements, identifying a technical solution, and onboarding practices. Results: This strategy ultimately produced real-time, population-level visibility of community-delivered MBH services within the hospital EHR, democratized community-based providers’ access to clinically actionable data housed within the hospital EHR, and is advancing MBH integration to enhance whole-child outcomes. Conclusions: MBH attribution has allowed for the creation of population-level dashboards that aggregate and share critical health information to external partner organizations and will serve as the backbone for additional clinical information exchange moving forward.