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Care Coordination

Community and Clinical Care (C3) Initiative

IDPH has contracted with six communities to implement the C3 Initiative.  C3s are multi-sector groups of stakeholders that include clinical-based healthcare providers, other community based providers, and public health organizations implementing innovative strategies and referral processes to meet the clinical and social needs of a defined population. These six communities were awarded through a competitive bidding process, and will continue this work through April 30, 2019.  The map below shows the C3 service areas (click on the picture to open a PDF):

The C3 Diagrams below are example referral flow processes for a C3 Initiative.  

C3 Diagram  Diabetes Example

(click on the image to enlarge)

Statewide Alert Network (SWAN)

The SWAN is a statewide system using hospital health information technology to send alert notices to providers when their patients use an emergency department or are admitted to a hospital. The SWAN is intended to give providers a real-time tool to monitor their patients’ major health events. The role of SWAN in SIM is to help providers better coordinate their patients’ care and especially their care as they transition from the ED or hospital setting back into the community. This enhanced care coordination should result in an overall reduction in preventable ED visits and inpatient readmissions. Implementation/impact measures under consideration for this component include number of alerts provided, average time between utilization and alert, and provider awareness and utilization of SWAN alerts. 

SIM Technical Assistance

The Iowa Healthcare Collaborative (IHC) will provide technical assistance in the area of quality improvement and training to the C3s.  IHC will be providing statewide Learning Community events for professionals working on similar initiatives.  Targeted for care coordination teams, hospitals, managed care companies, state public health officials, healthcare providers, community-based and long term support providers, the conference will be an excellent opportunity to get updates on SIM initiatives, learn about ways that communities are working together to make a difference, and identify opportunities that can be implemented within communities.    

Links and Resources

Partner Websites