Numerous studies have demonstrated the effectiveness of multidisciplinary community-based care teams in improving health and social outcomes for individuals and households receiving Medicaid. Roving teams of care workers can bridge a significant gap between traditional primary care practices and patients whose health is largely influenced by factors beyond the clinic walls.

Despite their potential, community-based care teams often face challenges that stem from inadequate funding, insufficient recognition, and a lack of purpose-built technology to support their work. As a result, these teams are often burdened with excessive manual labor that contributes to burnout. Moreover, they lack access to the technical teams needed to design software that can scale their programs across diverse communities, healthcare settings, and existing healthcare data platforms.

Waymark's Customized Software Solution for Community-Based Care Teams

To address common barriers faced by community-based care teams, we developed an internal software platform designed in partnership with community-based care teams. Based on extensive user research and our team's deep experience in healthcare software design, engineering, and product development, Waymark's internal software platform is intentionally designed to amplify the impact of hyperlocal programs.

Our platform stands out because of its orientation around patient goals and the communication and information systems necessary to achieve them. In contrast to software anchored around typing long provider encounter notes and ensuring these notes maximize billing codes and their required documentation, our platform is oriented around the modern approach of rapid, short communications around the goals each patient identifies to our team and how well our team is achieving them. Team members access common modern communication and automation systems—including direct SMS texts to patients and internal chat—missing from typical health record systems, enabling them to branch out and collaborate with patients and with each other on each goal, then rapidly update each other as they focus their time on coordination of care. 

As care team members identify manual pain-points that commonly lead to arduous workarounds for care coordinators in healthcare, our embedded user experience and design teams work with our engineers to modify user interfaces, then prototype and test opportunities for producing efficiencies and automation. This approach of ‘participatory design’ differs from a traditional healthcare software creation approach that focuses on billing and administrative coding requirements. All of us have seen providers fighting with their computers or facing the screen instead of facing their patient; they are commonly required to complete orders or notes in awkward templates, due to the focus on meeting billing requirements. Because Waymark operates under capitated, value-based financial arrangements, our care teams are free from billing constraints–and our software can be as well. 

Unlike traditional customer relationship management (CRM) systems, our software platform is proactive, designed to focus on prioritized outreach for roving teams, rather than reactive call-center customer service. Our platform does not require a software installation or app download from patients, health plans, or the practices we serve. It allows team members, patients, and primary care providers to interact through their preferred modalities, and at the time and cadence that’s optimal for them. It facilitates our team’s response to real-time notifications and location information on patients in crisis. Our back-end data systems include rapid notices (within 15 minutes) from local emergency rooms and hospitals when a patient arrives at such a facility–enhancing our opportunity to meet a patient face-to-face, even if they may not have a stable phone number or address.

Our platform provides our care team members with the information they need to focus on patients' goals rather than on activities like interpreting a faxed document from a pharmacy and reconciling its elements manually with the medication list in an electronic health record. The platform presents data in a user-friendly and customizable interface that reveals only relevant insights to our teams. Critically, our organizational structure then enables care teams to provide both continuous and discrete structured feedback to our user experience, design and quality improvement experts, to create a system of rapid-cycle improvement.

Streamlining Patient Care

Drawing on our care team members' extensive experience with building and using existing healthcare software solutions, our software was designed to eliminate the manual labor and time-consuming tasks that often frustrate care teams. By creating a generalizable platform to make common activities more efficient to perform, the software enables care team members to spend less time on tedious administrative tasks and more time on meaningful conversations and planning for the achievement of patient goals. For us, the system also allows each new care team member to learn and benefit from the care team members that came before them and help to create workflows to common challenges faced in roving, community-based care.

Purpose-built software can facilitate the scaling of evidence-based interventions across communities, enabling care teams to prioritize patient care over cumbersome, billing-focused systems.

As we continue to develop, implement, and refine purpose-built solutions, our goal is to catalyze a shift toward data-driven, multidisciplinary, community-based care models for patients receiving Medicaid. By empowering care teams with the right tools and supportive technology teams who listen to them, we can transform the way care is delivered and improve health outcomes for those who need it most.

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