Appl Clin Inform 2020; 11(04): 617-621
DOI: 10.1055/s-0040-1715894
Case Report

Empowering Caseworkers to Better Serve the Most Vulnerable with a Cloud-Based Care Management Solution

Jane L. Snowdon
1  Center for Artificial Intelligence, Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, United States
,
Barbie Robinson
2  Department of Health Services, County of Sonoma, California, United States
,
Carolyn Staats
2  Department of Health Services, County of Sonoma, California, United States
,
Kenneth Wolsey
3  Cognitive and Analytics Practice, IBM Global Business Services, San Diego, California, United States
,
Megan Sands-Lincoln
1  Center for Artificial Intelligence, Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, United States
,
Thomas Strasheim
4  IBM Cloud and Cognitive Software, IBM Watson Health (retired), Denver, Colorado, United States
,
David Brotman
1  Center for Artificial Intelligence, Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, United States
,
Katie Keating
1  Center for Artificial Intelligence, Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, United States
,
Elizabeth Schnitter
1  Center for Artificial Intelligence, Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, United States
,
Gretchen Jackson
1  Center for Artificial Intelligence, Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, United States
5  Surgery, Pediatrics, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
William Kassler
1  Center for Artificial Intelligence, Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, United States
› Author Affiliations
Funding None.

Abstract

Background Care-management tools are typically utilized for chronic disease management. Sonoma County government agencies employed advanced health information technologies, artificial intelligence (AI), and interagency process improvements to help transform health and health care for socially disadvantaged groups and other displaced individuals.

Objectives The objective of this case report is to describe how an integrated data hub and care-management solution streamlined care coordination of government services during a time of community-wide crisis.

Methods This innovative application of care-management tools created a bridge between social and clinical determinants of health and used a three-step approach—access, collaboration, and innovation. The program Accessing Coordinated Care to Empower Self Sufficiency Sonoma was established to identify and match the most vulnerable residents with services to improve their well-being. Sonoma County created an Interdepartmental Multidisciplinary Team to deploy coordinated cross-departmental services (e.g., health and human services, housing services, probation) to support individuals experiencing housing insecurity. Implementation of a data integration hub (DIH) and care management and coordination system (CMCS) enabled integration of siloed data and services into a unified view of citizen status, identification of clinical and social determinants of health from structured and unstructured sources, and algorithms to match clients across systems.

Results The integrated toolset helped 77 at-risk individuals in crisis through coordinated care plans and access to services in a time of need. Two case examples illustrate the specific care and services provided individuals with complex needs after the 2017 Sonoma County wildfires.

Conclusion Unique application of a care-management solution transformed health and health care for individuals fleeing from their homes and socially disadvantaged groups displaced by the Sonoma County wildfires. Future directions include expanding the DIH and CMCS to neighboring counties to coordinate care regionally. Such solutions might enable innovative care-management solutions across a variety of public, private, and nonprofit services.

Protection of Human and Animal Subjects

All reported findings in this case review used aggregated community-level data and deidentified case findings, reporting no unique identifiers. This case report has IRB approval or the equivalent ethics committee approval from Sonoma County.




Publication History

Received: 08 April 2020

Accepted: 22 July 2020

Publication Date:
23 September 2020 (online)

Georg Thieme Verlag KG
Stuttgart · New York