Care Coordination

Equipping the delivery system with care coordination tools provides new innovative processes to transform how health care is delivered in Iowa. Iowa’s SIM model will equip the delivery system with two new tools. Ultimately these two care coordination tools equip the delivery system to improve population health, transform how health care is delivered and positively impact the cost of health care in Iowa.

1. Community Care Coalitions (C3)
The state will foster the development of C3 to provide assessment and referrals to needed community and social services that are often left underutilized by our current delivery system. The C3 also act as a community convener that will drive rapid cycle performance improvement strategies.Currently, there are six C3 Communities spanning 20 counties in Iowa. Read more about the C3 Communities by accessing the Community Care Coalition (C3) Initiative Program Highlight.

2. Statewide Alert Notification (SWAN) System
The state is investing in a technology infrastructure to develop a statewide network of hospital Admission, Transfer, Discharge (ADT) data to provider real-time alerts to provider organizations in value-based payment arrangements. This system is known as SWAN, the Statewide Alert Notification system. These alerts inform providers during critical transitions of care which is a proven tool to achieve better health care utilization and outcomes.

Secondary Drivers for Care Coordination
Care Coordination is a driver to positively impact preventable Emergency Department (ED) visits, preventable readmissions and improve the health in the three areas of diabetes, tobacco and obesity. Getting care coordination right will transform how health care is delivered in Iowa. The Iowa SIM initiative will work to align the health care delivery system by equipping communities, informing stakeholders, and executing statewide strategies. C3 communities will engage local networks of community partners to lead person-centered coordination of care addressing clinical and Social Determinants of Health (SDH) needs. The SWAN aims to facilitate coordination during critical transitions of care (ED and inpatient events). Rapid Cycle Performance Improvement (RCPI) and Technical Assistance (TA) support will align and equip communities and health providers to increase effectiveness and accelerate results during the Iowa SIM Initiative. 

  1. Execute integrated community-based strategies
  2. Inform providers for better care coordination
  3. Execute care coordination models
  4. Optimize use of Health Information Technology (HIT)
News and Announcements
  • Five Iowa Health Systems Launch Statewide Alert Notification System: Iowa Medicaid Enterprise (IME) and the Iowa Department of Public Health (IDPH) are pleased to announce five Iowa health care systems have begun using the Statewide Alert Notification (SWAN) system. This tool provides real-time, secure notifications to care teams regarding emergency room visits, admissions and discharges of their members. Read more
  • Branstad, Reynolds Announce State Innovation Model (SIM) Initiative Communities: At the Administration’s February 29, 2016 morning press conference, Gov. Terry Branstad and Lt. Gov. Kim Reynolds announced that six communities are receiving grants for the State Innovation Model (SIM) Initiative. These six communities spanning 20 counties will engage in broad-based health care system and payment reforms over the next three years that will lead to better health outcomes and lower costs. Read the press release issued by the Governnor's Office. 
  • Award of Community Care Coalition (C3): The State Innovation Model Community Care Coalition (C3) Initiative Notice of Intent to Award has been posed to the IDPH website. The six awarded C3 applicants include three developmental initiatives and three implementation initiatives, and represent a total of 20 counties across the state of Iowa. The C3 communities will begin work on March 7th, 2016. 

Information Resources 

Partner Websites