Connecting Data to Person-Centered Care in Connecticut

By Heidi Wilson, Director of Services, Connie

In March, I was fortunate enough to speak at the State HIT Connect Summit about how Connecticut is using data to support person-centered care in home and community-based services (HCBS) programs. 

The discussion centered on a challenge that many states face: how to effectively support care coordination among various organizations that may all be serving the same individual but often lack access to the same information. 

In Connecticut, HCBS providers range from large organizations supporting thousands of clients to small agencies serving only a handful. Some are home health agencies, while others provide services such as homemaker support or companion care. 

All of them play a role in helping people safely remain in their homes. Historically, they haven’t always had visibility into what the rest of the care team is doing, making coordination difficult. 

Supporting a Statewide Initiative 

To address this, Connecticut’s Department of Social Services launched a value-based payment initiative designed to improve coordination across HCBS providers and support better outcomes. 

The effort brought together several partners, including the state’s Access Agencies, the National Committee for Quality Assurance (NCQA), universities supporting the program’s VBP design and outcome metrics, and Connie, Connecticut’s statewide health information exchange. 

Our role at Connie was to help bring together the information needed to support better coordination and outcome metrics. 

Making Data Actionable 

Using Connie’s health information exchange infrastructure, we integrated multiple data sources to support DSS’s program, including: 

• Hospital admission and discharges  

• Universal assessment data 

• Person-centered goals identified during care planning 

• Electronic visit verification and prior authorization data 

  
  

We then developed a platform specifically for organizations participating in the program with the goal of giving participants meaningful insights they could use in their daily work. 

Aligning Care Around What Matters to Patients 

Care managers work with individuals to identify priorities that matter most to them. These can be deeply personal and often extend beyond traditional clinical outcomes. 

For example, someone might want to build the strength needed to attend a family event or maintain the independence required to stay at home. 

Historically, those aspirations often remained within a single organization’s records. Through this platform, the broader care team can now see and support those goals. 

When providers understand what someone is working toward, they can better align their services to help that individual succeed. 

Turning Information into Better Coordination

The platform provides participating organizations with two main tools: a dashboard showing performance on key outcome measures, and a client worklist that highlights important information about individuals they serve. 

Providers can see when a client has been admitted to or discharged from the hospital, identify individuals who may need additional support, and view person-centered goals set during care planning.

These insights help organizations prioritize outreach and coordinate with others involved in a client’s care.

Another insight we heard repeatedly from providers was the value of hospital notifications. Many HCBS providers previously had limited visibility into hospitalizations and knowing when a client has been admitted or discharged allows them to follow up quickly and provide additional support.

Providing Data to Support the Work Providers Already Do

Simply providing data isn’t enough as organizations need time to understand how new information fits into their existing workflows.

Because many HCBS providers spend more time with individuals in their homes than anyone else, they are often the first to notice when something has changed. When that information is shared across the care team, it can help trigger earlier support and prevent larger problems.

Programs like this demonstrate how shared data can strengthen coordination across healthcare and community-based services. With the right information reaching the right providers at the right time, it becomes much easier to support individuals in achieving the goals that matter most to them.