Accelerating Outcome Improvement Through Care Coordination Technology 2-1-1 San Diego and Unite US

Agenda Organizational Histories Approach to Technology Current State Accelerating Outcome Improvement Through Care Coordination Technology William York, 2-1-1 San Diego Taylor Justice, Unite US Agenda Organizational Histories Approach to Technology Current State Future Plans Integrated Care Coordination

2-1-1 Transforming Access to Human Services "We find that the Information & Referral Petitioners have demonstrated sufficient public benefits to justify use of a scarce public resource and we therefore assign 2-1-1 to be used for access to community information and referral services.” ~ Federal Communications Commission's final order to assign 2-1-1 on July 21, 2000

History 2015 Vision Shift from I&R to whole person care 2005 Program of United Way - a Partner we still have today 2005 Launched as 2-1-1, as the region's only 24/7, free, 3-digit dialing code for community health and disaster services. Answered 85,000 calls first year in operation 2009 Secured CalFresh Outreach Contract Upgraded to commercial "cloud based" telephony system 2013 Earns 5-year AIRS re-accreditation; received VTCLI grant to re-create our current technology system 2011 Relocated to “State of the Art” facility 2000 Transitioned to INFO LINE a separate non-profit after Atlanta launched the first 2-1-1 in 1997 2007 Becomes AIRS accredited agency Major responder to the San Diego County Firestorm that raised awareness of 2-1-1 by 60% 2010 Signed a “sole source” contract with the County of San Diego. The County launched the Live Well San Diego initiative 2012 Partners with community agencies to provide “Courage to Call” peer helpline support CIE incubated within 2-1-1 2016 Acquired Community Information Exchange Moved into “Connections Center” and redesign for person-centric 2014 Launched the 2-1-1 Re:Volution

Information & Assistance Current Future Care Coordination Information & Assistance Basic I&R

It all begins with one person, one family Housing/Shelter Food Assistance Financial Assistance Healthcare Transportation

Connecting Service Providers Community Services Utility Assistance Housing Financial Literacy Programs Military / Veteran Services Crisis Services Meals Disaster Coordination Public Benefits Aging Services Health Benefits Childcare Transportation

Integrated Cross-Sector Collaboration

Risk Rating Scale Common system for identifying client barriers and outcomes through the Social Determinants of Health Individual (age, gender, race, language) Behavior and Choices (smoker, eating habits, exercise, drug use) Access To (healthcare, housing, food security, employment) Environment (sidewalks, parks, public transportation) Community/Politics (laws, neighborhoods)

Technology Identify data fields, sources and alerts to enhance care coordination Review hardware, software and staff capabilities with targeted CBO’s Survey technology alternatives for make, buy or leverage options Acquire technology access for data viewing/sharing Pursue Application Program Interfaces and Single Sign-On Develop display format for client-specific data and aggregate reporting

Approach to Technology Adoption Streamline community assessment flows Provide cross domain service outcomes Multi-channel access to enrollment Community defined expansion of domains Overlay of backbone support to existing community collaborations Align with other infrastructure organizations

Privacy & Security Myths and Realities Clients reluctant to share personal data HIPPA bars information sharing Agencies unwilling to share client data Few legal mechanisms available to govern data sharing Process to establish data exchange to onerous Clients want to minimize personal history HIPPA enables data sharing for treatment (includes care coordination/referral Agencies eager to see whole person view of client Participation Agreements, BAA & client consent How to build CIE in own community provides template

Key to Adoption Issues PEOPLE PROCESS INFORMATION Technology Workflow Staffing Management Value Data User Experience Behavioral Health Single Sign-On Agency Metrics Case Manager Workload Performance Expectations PEOPLE PROCESS INFORMATION

If you want to go fast, go alone; If you want to go far, go together. - African proverb

Coordinated Care Network Technology People

We Enhance the Connection Between THE PEOPLE TO THE PEOPLE who need it the most who care

Program Processes Shape the Delivery of Human Services. PROGRAMS HUMAN SERVICES

What We Observe Consumer Discontinuity Slow Processes Little to No Measurement

Reinventing the Delivery of Human Services Collaboration & Coordination Human-Centric

How We Do It Build curated coordinated care solutions for innovate communities Provide a centralized resource for consumers in a broad range of service categories Facilitate and track impactful communication

How It Works COORDINATION CENTER

Coordinated Networks across the Country 4 Average Veteran in the network reports 2 needs Top requested services are Employment Housing Education Legal Services Benefits 4

Collective Impact Pillars All participants have a shared vision for change including a common understanding of the problem and a joint approach to solving it through agreed upon actions Common Agenda Collecting data and measuring results consistently across all participants ensures efforts remain aligned and participants hold each other accountable. Shared Measurement Participant activities must be differentiated while still being coordinated through a mutually reinforcing plan of action. Mutually Reinforcing Activities Consistent and open communication is needed across the many players to build trust, assure mutual objectives, and create common motivation. Continuous Communication Creating and managing collective impact requires a separate organization(s) with staff and a specific set of skills to serve as the backbone for the entire initiative and coordinate participating organizations and agencies. Backbone Support San Diego Veterans Coalition Unite US Software Dedicated Workflow Meetings, Email Newsletters C2C, Steering Committee

Network Roles Veterans & Families Points of Entry Coordination Center Call Email Web form Service Providers Walk-in Service Providers Actions Receive a Referral Accept Reject Create a Referral Send Manage a Case Edit/Update Close Track Coordination Team Actions Assign Manage a Referral Recall Edit

Path to Provider Engagement Each step in the below process is an opportunity to reinforce an understanding of what the Network is, how it will work, and how Providers can maximize value through best-in-class participation and engagement. The more they contribute and engage during the development, the more likely the end result will align with their needs as an organization and their strategy to serve. 1. Network Model Selected 2. Service Area & Domains Defined 2. Provider List Review 3. Software Configuration Review 4. Review of Network Design and Agreements 5. Training 6. “Open for Business” Present and agree upon the Network Design parameters. Request feedback and input, and invite questions. Network Model. Will there be a central backbone organization or a Provider-to-Provider interface? Or a mix? Service Region. What is the area that we want to cover? Service Domains. What are the foundational categories that we want to offer? How will we categorize services? Provider List. Do we have the right list of providers? Are we comprehensive enough? Who is missing? Intake Forms. What data points should be captured by Service Domain? Providers should supply their intake assessments to inform the software configuration. Review the software configuration and gather feedback from the group. Are the data points important to your organization represented? What is missing? Review of Network Mechanics, all agreements, including Participation Agreement, End-user License, and Global Informed Consent; goal is to set expectations on user policy and workflow. Invite feedback, questions and input. Train all the provider staff, intake coordinators, navigators and case managers who will be using the software. NOTE: Coordination Team will have a designated training that will include how to support providers and mentor them in the new software and workflow. Clearly communicate a launch date where all Providers will begin using the new software and workflow. Expect to take questions and support users as they navigate this new process for the first two to four weeks of Network launch NOTE: Launch can be defined in stages, with a preliminary “soft” launch and a public-facing “official” launch, if desired.