Keywords
artificial intelligence - data integration hub - process improvement - care coordination
- emergency care
Background and Significance
Background and Significance
Lack of affordable housing, mental illness, substance abuse, and natural disasters
have contributed to a growing homelessness crisis in California, estimated at 38 per
10,000 people in 2019, or twice the national average of 17 per 10,000 people.[1] According to the 2019 Point in Time Homeless Count, Sonoma County was among the
top three suburban counties with 60 homeless per 10,000 people and has the highest
per capita homeless in the United States.[1] Sonoma County is largely a rural region with a diverse population of approximately
500,000, and exhibits significant disparities in health outcomes, living standards,
and educational attainment.[2] State and local government agencies that serve the homeless are faced with increasing
demand for services as well as budgetary, organizational, and legislative constraints.
Typically, agencies are separately funded and staffed, and they operate in “silos
of service” with limited interagency integration.[3] Recent disasters have demonstrated the importance of strengthening government organizational
systems to help communities respond to naturally occurring threats through the evolving
field of emergency management.[4]
Recognizing a lack of agency integration as a barrier to support vulnerable citizens,
Sonoma County, California implemented a cross-program care coordination tool within
their safety net system in early 2017. Sonoma County sought to design and deliver
coordinated service for individuals experiencing one or more complex needs, including
unemployment, housing insecurity, homelessness, behavioral health issues, substance
abuse, and incarceration. The County's siloed departments (e.g., Health Services,
Human Services, Housing Services, Child Support Services, Probation, and others relating
to criminal justice) collaborated through advanced care-management tools to decrease
care fragmentation for shared clients; reduce duplication of services; and create
an effective, efficient care management plan.[5]
[6] Sonoma County's aim was to improve the health, well-being, and self-sufficiency
of clients; increase access and referrals to services; grow sustained client engagement;
improve communication between care managers; and decrease expenditures per client/family
through improved efficiencies.
During implementation, the Sonoma County Complex fires hit, burning more than 36,000
acres, killing 22 people, and destroying 5,636 homes and buildings.[7] Sonoma County is challenged by a high cost-of-living, limited housing, and a homeless
crisis exacerbated by the 2017 fires. The need for safety net services intensified
during the wildfire response and continued throughout the long recovery process. In
the aftermath of the wildfires, many vulnerable citizens were already living in shelters
and required ongoing shelter, while others displaced from their homes required shelter
and were faced with dwindling supply.
Objectives
This case report describes the system implemented, workflow changes, and impact on
vulnerable citizens to inform the field of informatics about lessons learned from
this innovative application of care-management tools.
Methods
Sonoma County created the Accessing Coordinated Care to Empower Self Sufficiency (ACCESS)
Initiative to achieve their objectives of access, collaboration, and innovation for
the most vulnerable residents by matching them with services to help improve their
well-being and resilience. The determination of whether an individual is vulnerable
is a hybrid approach comprised of agency interviews, a risk assessment, the ascertainment
that the person has urgent needs, or an external event, such as a wildfire or tornado,
that triggers a dramatic increased need for assistance. The ACCESS Initiative consists
of the Interdepartmental Multidisciplinary Team (IMDT) approach to generate and deploy
coordinated cross-departmental services for addressing housing insecurity needs and
to inform technology strategy and development. Care management by the IMDT had a community-wide
perspective and participation by community partners to decrease fragmentation of care
across community clinics, regional hospitals, and social service providers. The formation
of the IMDT was achieved over several months through a series of meetings to discuss
interdepartmental processes. Memorandums between agency department heads were established,
which included agreements for data sharing in a manner that was consistent with their
department's policies. ACCESS governance was implemented by a Safety Net Collaborative
Steering Committee, who regularly reviewed system and data needs, uses, and privacy.
IBM implemented a data integration hub (DIH) and care management and coordination
system (CMCS) for Sonoma County in 90 days. The DIH, IBM Connect 360, working with
IBM InfoSphere Master Data Management, brought together data from a variety of sources
using proprietary and highly accurate probabilistic matching and search algorithms,
and created a single, integrated, current master data index resulting in a “golden
record” for every individual. In the center of [Fig. 1], the “single view of the individual” is the result of the process of ingesting EMR
and social determinants of health data to provide a holistic view of the individual
from the multitude of structured and unstructured sources on the right side of the
diagram. More than 91,000 resident records were loaded into the DIH from four sources
(CalWIN for eligibility operations, SWITS for drug and alcohol dependency, Avatar
for mental health, and IJS for proprietary justice data). Depending upon the agency,
the frequency that data feeds are refreshed ranges from every 15 minutes to daily.
The research team conducted a validation of the “golden records” prior to the system
being put into operation. The DIH allowed secure exchange of client data, which could
be stored on-premise or on the IBM cloud, across existing systems.
Fig. 1 IBM Connect 360 and Watson Care Manager Solution Ecosystem.
The CMCS, IBM Watson Care Manager (WCM), was built on a Health Insurance Portability
and Accountability Act (HIPAA)-enabled, cloud-based platform that can aggregate data
and connected agencies, payers, and community service providers, to support the design,
coordination, and delivery of individualized services. Using multidisciplinary teams,
case managers, social workers, and treatment providers optimized workflow for activities
such as scheduling, developing individualized care plans, managing budgets, selecting
providers, and enabling care for an individual's mental health, physical health, and
social service needs. The CMCS applied best practices through structured programs
built in alignment with evidence-based medicine, quality standards, and regulatory
requirements. The CMCS's artificial intelligence (AI) component can automatically
extract and surface social determinants of health and clinical health terms in large
volumes of care management notes.[5]
[8]
The integrated IBM Connect 360 and WCM solution is available on tablets, laptops,
or mobile devices and offers interoperability with third-party services including
PayPal for provider/service payments, provider registry and accreditation, and Google
for maps and location, although these third-party services were not deployed in Sonoma
County. Analytics and business intelligence are used to identify cohorts and trends
and to send and receive alerts and notifications. The CMCS allowed the IMDT to create
and manage a new fire-displaced cohort, perform assessments, record case notes, set
care plans, and match client needs with community providers.
Results
More than 4,000 fire victims were initially housed in shelters. Two weeks after the
disaster, approximately 300 individuals did not have secure housing. Of 127 individuals
representing 95 households that remained in shelters, approximately 42% were identified
as precariously housed and approximately 26% were homeless prior to the fires. Over
the 10-month period from April 2018 to February 2019, the IMDT and care managers identified
and managed 77 clients (median age 54.5 years, [29–84], female [58%]) with multidimensional,
complex needs (34 cases stable and intermittently monitored, and 43 actively managed).
These 77 fire-displaced, homeless individuals required intensive case management and
exhibited much higher utilization of MediCal (99 vs. 80%) and rates of mental illness
(97 vs. 67%), medical conditions (82 vs. 28%), substance abuse (60 vs. 47%), and emergency
room utilization (17 vs. 10%) than the other clients (more than 1,000) served by ACCESS
Sonoma. Applications for food stamps, Section 8 housing, and Medi-Cal for these complex
individuals were prepared and thoroughly reviewed by IMDT, reducing the burden on
multiple staff. The average number of times IMDT formally discussed cases was 2.9.
The IMDT's goal is to help clients progress toward self-sufficiency by providing care
coordination to support them in behavioral health treatment, employment and income
security, suitable and stable housing, food security, substance use treatment, physical
health services, disability management, and reduced recidivism. Client needs are elucidated
by the case worker during an encounter, while performing assessments, and via data
viewed in the system about assessments and case notes. County residents who are eligible
for services must “opt-in”; however, not all of them chose to engage in services.
Every client who “opts-in” is monitored. Clients may be monitored less frequently,
or cases may be closed due to a client stabilizing, being rehoused, engaging with
other collaborative care providers, or an inability to establish or maintain contact.
Two clients, Sandy and Martin (pseudonyms), faced difficulty accessing and navigating
multiple service programs. Sandy, a 69-year-old woman with chronic obstructive pulmonary
disease and living on a very modest income has a son with substance abuse issues who
threatened her, so she sought refuge in Sonoma County. The trauma of being homeless
and abused led to behavioral health challenges that went untreated. She often visited
the emergency room (ER).
After the 2017 wildfires, Sandy arrived at a homeless shelter to avoid smoke. Two
weeks later, the Federal Emergency Management Agency began to close the shelters.
Sandy was among approximately 300 individuals and families with unmet needs and no
place to go. A mental health caseworker quickly realized Sandy needed a higher level
of care and asked permission to share her vital information, thereby allowing the
IMDT to coordinate appropriate services (e.g., Medi-Cal, food stamps, Section 8 Housing).
Sandy's bank statements revealed she was paying for multiple insurance policies. Eliminating
one policy by having Medi-Cal pay for her Medicare insurance provided Sandy with additional
income. IMDT workers connected Sandy with a health care provider who addressed her
chronic pain, subsequently ending the need for ER visits, and resulting in significant
cost savings. Sandy is healthier now than before the fires. Through care coordination,
Sandy was able to obtain health insurance, financial assistance, housing, and mental
health services and support.
Martin is a 50-year-old man, who has been homeless for more than 10 years, with physical
and behavioral health needs. Staying in Guerneville, California and a high utilizer
of health services, Martin is out-of-work, has been in and out of jail several times,
and started living on the streets after his wife's death. Due to increasing behavioral
health and substance-abuse issues, Martin ended up in crisis stabilization services
ten times. The IMDT established contact with Martin at a shelter in September 2018.
He received rehabilitation services to deal with his addiction and behavioral health
issues. In October 2018, Martin became sober for the first time in 10 years. The IMDT
helped him find a job, thereby reducing his utilization of economic assistance. In
April 2019, Martin moved into permanent housing. Martin is now able to engage in society
in a functioning manner since he received the needed services.
These case examples illustrate how Connect360 and Watson Care Manager improved operational
efficiency and interdepartmental teamwork, and how successful coordinated care may
improve citizen outcomes. Prior to deployment of the CMCS, the IMDT took approximately
4 hours to discuss and provide status updates for approximately 10 homeless people
on their housing placements, financial assistance from the state, and health care
services. In comparison, after the solution's deployment, the IMDT took approximately
4 hours to discuss and provide updates for approximately 30 to 45 homeless people
depending upon the complexity of their cases. Additionally, the CMCS empowered the
IMDT to redirect homeless people out of the ER, connect them with suitable insurance,
establish care plans, and match them to appropriate health care services more quickly.
Benefits realized included reduced duplication of services, increased use of cost-effective
treatment, decreased overall expenditures (ER visits), increased awareness of services
and programs offered by other departments, and reduced recidivism.
Discussion
Care-management solutions are typically developed for the treatment of chronic illnesses
in the ambulatory setting.[9]
[10]
[11] This case report describes how an innovative application of a care-management solution
helped care management workers transform safety net services, social well-being, and
health care for disadvantaged groups displaced by a natural disaster. Key functionalities
were integration of siloed data and services, AI to surface social determinants of
health and clinical health terms from structured and unstructured sources, matching
of clients with services, and a unified view of citizen status that supported coordinated
care. The cases of Martin and Sandy illustrate how Sonoma County employed the system
to establish stability with respect to behavioral and physical health and associated
social circumstances. The case report generated hypotheses for future research studies
to examine actual or forecasted expenses, cost avoidance, and health outcomes for
cohorts (e.g., fire-displaced, mentally ill) and assess usability. In 2019, the Kincade
fire hit more than 75,000 acres in and near Sonoma County with evacuations estimated
at 180,000 residents.[12] The potential exists for improving integrated collaborative networks across the
region with incorporation of data and services from surrounding counties.[13] Sandy's and Martin's challenges are common to homeless individuals. Using the integrated
IBM Connect 360 and WCM solution, governmental services were equipped to serve the
most vulnerable residents like Sandy and Martin.
Sonoma County executives, supervisors, and frontline workers from each agency were
involved in defining the requirements for the integrated DIH and CMCS system. IMDT
members helped to configure the software. These knowledgeable users participated in
a half-day training session and found the solution to be very intuitive; thus, they
were eager to use the system. New users participated in a full-day training session.
Creative collaborations among public, private, and non-for-profit organizations are
likely needed to address adequately the homelessness crisis in the United States.
Care management tools that can provide integration and collaboration across diverse
service providers may enable the needed solutions.
Conclusion
This innovative application of a data hub and AI-enabled care management solution
aggregated near real-time data for caseworkers, clinicians, housing specialists, and
other community workers who served Sonoma County citizens. Individual users involved
in this study reported improved operational efficiency, information transparency,
access to coordinated care, and citizen outcomes. Advanced health information technologies
can be instrumental in driving collaboration and governmental service access so that
residents at risk and experiencing a crisis can be better served in their greatest
times of need.
Clinical Relevance Statement
Clinical Relevance Statement
Care management tools are traditionally applied in chronic disease or primary care
settings. This case study describes the implementation and value of a care management
solution applied to governmental services.
Multiple Choice Questions
Multiple Choice Questions
1. The study presented here is:
Correct Answer: The correct answer is option c, case study.
2. Which response below best describes how AI and advanced health information technologies
can be transformative in delivering a rapid response system in the event of a natural
disaster?
-
Improved care coordination.
-
Better information transparency.
-
Matching and search algorithms for services.
-
All of the above.
Correct Answer: The correct answer is option d, all of the above.
