At Alameda Health System (AHS), we continue to be thoughtful about our ongoing commitment for identifying the right patients at the right time for the most appropriate coordinated care. Thanks to the recent implementation of Compass Rose, a comprehensive care management module in Epic, our community health teams are now better equipped to improve our patients’ total health and wellness.

“Compass Rose provides our staff the ability to efficiently plan, provide and document team-based, patient-centered care,” said Lilly MacRae, RN, PHN and the director of community health.  “It also enables us to demonstrate our impact and monitor population outcomes.”

The project has been in the works since 2021 when AHS applied for the CalAIM Incentive Payment Program from our Medi-Cal managed care partners, Alameda Alliance and Anthem Blue Cross.  The kick-off for the Compass Rose build and implementation began in March 2023 under MacRae’s direction.

She shared that over the span of six months a cross-functional team comprised of department leaders, frontline staff, a project manager, information system (IS) analyst and the Epic team worked tirelessly to build, iterate, train and test Compass Rose to ensure a successful implementation.

Two key members of the implementation team, Barry Chiang, manager, ambulatory applications and Kim Peterson, applications analyst III were instrumental in building and designing the application’s functionality to meet the day-to-day needs of the care management end users.

“Compass Rose allows users to manage and track patient care throughout the entire outreach and care management process including collaborating on individual care plans and connecting patients with community services and other providers to help patients meet their goals,” said Chiang.

As end users, and credentialed Compass Rose trainers, Marco Hernandez, health advocate program coordinator and Joseph Ramirez, RN, care transitions served on the implementation team to help inform work flows and support new users for a smooth transition.

“Compass Rose brought a 70% change in our workflows and that can be scary for some,” said Hernandez. “Ultimately, the feedback from the end-user perspective has been very positive about the ease of use and increased access to reporting tools to measure success and evaluate the level of services our patients receive.”

The Compass Rose module enables AHS staff to combine social and health-related insights into a comprehensive, patient-centered record to assess patients’ social determinants of health (SDOH) and track patient outcomes across their continuum of care.

Understanding SDOH; what they are and what actions to take, as well as the efficacy of those actions is critical to AHS’ population health management strategy.  SDOH include factors such as housing, food and nutrition, transportation, social and economic mobility, education and environmental conditions.

With the implementation of Compass Rose, AHS’ community health department comprised of complex care management, care transitions, enhanced care management and health advocates staff are able collaborate to address the various SODH that impact the community we serve.

“Compass Rose empowers our teams to deliver individualized and focused care to some of our system’s most vulnerable patients in need,” said Ramirez. “By leveraging this technology, together we are building a healthier community.”