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

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

3. 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 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

10. 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 in 1997
2007
Becomes AIRS accredited agency
Major responder to the San Diego County Firestorm that raised awareness of 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 Re:Volution

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

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

13. 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

14. Integrated Cross-Sector Collaboration

15. 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)

16. 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

17. 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

18. 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

19. 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

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

21. Coordinated Care Network
Technology
People

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

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

25. What We Observe Consumer Discontinuity Slow Processes
Little to No Measurement

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

27. 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

28. How It Works
COORDINATION CENTER

29. Coordinated Networks across the Country4
Average Veteran in the network reports 2 needs
Top requested services are
Employment
Housing
Education
Legal Services
Benefits 4

30. 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,
Newsletters
C2C, Steering Committee

31. Network Roles Veterans & Families Points of Entry
Coordination Center
Call
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

32. 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.