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Connecting Social Services Data and Teams in Southern Oregon

June 15, 2015
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Community Connected (C2) Network seeks to enhance referrals and increase engagement

Recently I wrote about a June 2 meeting of the federal Health IT Policy Committee’s Advanced Health Models and Meaningful Use Workgroup that focused on the challenges and benefits of integrating data from medical and human service organizations. The workgroup hopes to use the input to develop recommendations about the IT infrastructure that would support advanced models of care.

Speaking at that hearing, Nancy Garrett, chief analytics officer at Hennepin County Medical Center in Minnesota, said, “If you take care of somebody with diabetes and they live under a bridge, you have to pay attention to housing and food issues, or you will have no success at medical care.”

Last week I spoke with Stephanie Mendenhall, who is working on an effort to share data among human services agencies and medical providers in Jackson County in southern Oregon.

“We would like to move toward coordinated care plans and unified treatment plans,” said Mendenhall, service integration manager for Jackson County Health & Human Services. “We have high-needs folks in our community — families involved with 13 different organizations — but none of them are communicating about what they are seeing these folks for or what their plans are. So we feel like those inefficiencies could be resolved.”

To address the issue, Mendenhall’s organization is creating the Community Connected (C2) Network to provide a mechanism to connect and share data between existing data systems. One goal, she said, is to enhance referrals and increase engagement by creating opportunities for “warm handoffs” and coordinated care between provider organizations.

Some of the components envisioned for the C2 database include:

• Centralized contact registry

• Centralized resource and referral module

• Customizable views and dashboard

• C2 Network new tenant onboarding tool

• Release of information module

• Inter-tenant record-sharing capabilities

• Survey and assessment module

• Auto-populating of forms and summary sheets

• Integrated network calendar and discussion forum

• Aggregate data reporting

Database modules are being built between now and December 2015 by a third-party vendor, with production use beginning in the first quarter of 2016.

Providing initial funding and hoping to benefit from the C2 Network are Jackson Care Connect and Allcare, the two “coordinated care organizations” in Jackson County. The State of Oregon has created coordinated care organizations (CCOs) as networks of all types of providers (physical health care, addictions and mental health care and sometimes dental care providers) who have agreed to work together in their communities to serve people who receive health care coverage under Medicaid. CCOs are focused on prevention and helping people manage chronic conditions, like diabetes and they are accountable for health outcomes of the population they serve.

“The CCOs have a list of metrics they have to track,” Mendenhall explained, “and I knew that if we could create something that allowed them to have information in a centralized place that it would be of value to them.”

She said physical health providers are definitely interested in participating and getting a better understanding of the services their patients are using, and the Jefferson Health Information Exchange has partnered with Jackson County to create data-sharing opportunities between medical and social service providers.

“We want people to be able to make a referral and get a response back that yes the person engaged in services and have the data on the back end to prove across sectors who you are serving,” Mendenhall said. “That would also make us more eligible for federal grants.”

Clients benefit, too, she said, because when they walk into any social service organization that is part of this network, their records are available and in place.  If they change addresses, it is corrected across the board in the cloud. If they want to access services, their referral form could be auto-populated from the information in the system, she said.

Like panelists who testified before the HIT Policy Committee workgroup, Mendenhall said that ne of the challenges is going to be consent to share data and meeting HIPAA requirements.  “We also have privacy laws in Oregon that other states don’t have,” she added. “Alcohol and drug records are going to be our biggest obstacle, of course.”

 Another challenge for Mendenhall is creating a subscription model that works for the agencies of various sizes in the county to sustain the network beyond the initial grant funding to create it.

The work toward coordinating data systems is part of a bigger picture to coordinate care that has been siloed too long. “Social services have operated separately from hospitals and health systems, but with this new CCO system we are working really hard to make sure people come to our site as a deterrent to accessing the emergency room,” Mendenhall said. “So with these high-cost services that are happening on the medical side, can we partner to make sure those things don’t happen as often? We think that the more information that can flow back and forth, the better. Even if we just have a window into things that aren’t regulated by HIPAA law, it is a starting point and we can move forward from there. We live in a county where people are interested in partnering to serve people better.”