California’s county-level Whole Person Care pilot programs provided targeted populations with a range of comprehensive services and supports to address unmet needs such as homelessness. Alameda County used the grant funding to create a social health information exchange and community health record to enable cross-sector collaboration.
Cristi Iannuzzi, director of strategy and implementation for Alameda County Health Care Services’ Social Health Information Exchange and Community Health Record, gave a detailed description of the county’s effort during a webinar hosted by the California Health Care Foundation and Homebase, a nonprofit, public policy law firm that works with communities to develop effective and humane responses to homelessness.
During the Whole Person Care initiative, the county developed a care coordination model and a data-sharing model focused on healthcare and homelessness. The Whole Person Care program, Alameda Care Connect, was the sponsoring engine, but now the Health Care Services Agency manages that system.
“Most of the organizations that we have dealt with have access to one system, maybe two. The Alameda County social health information exchange is a body of work that brings together data feeds from multiple sectors and and re-discloses that information in a community health record to coordinate that care and bring out a more whole-person perspective for a client,” Iannuzzi said.
In the early phases they are focusing on the clinical, behavioral health care, housing, and crisis response, as well as the jail and legal system. The social health information exchange is really two things, she explained. It's a community of organizations that have agreed to share data under a set of rules guided by some of the federal and state regulations, and it is a technology platform. “We took the funding from Whole Person Care to build a platform on a pilot level to manage Whole Person Care, which was a relatively small population, a little under 100,000 people," she said. "But the idea was that for the future, it would be managing all of the safety net of Alameda County, which is what it does today, to keep data secure, manage who can see what and match identities across these disparate systems.”
The county rolled out the community health record in 2019. It allowed providers on the clinical and on the housing side to see a view of information curated for relevant client utilization, diagnosis, and who is in their social network, and who is in their care management network.
“Today, we have more than 30 organizations, 1,000 users and 100 or more programs within those organizations that have been onboarded and are using that community health record, which is really important, because as we're sharing information across those providers, that's how they stay connected to do care coordination,” Iannuzzi said.
In addition to developing data-sharing agreements between organizations, the county had to develop patient or client consent agreements and incorporate them into the community health record. The county engages the client about what they will agree to share with providers across the care continuum. “There are HIPAA-covered entities that share a lot of information across that continuum,” she explained. “We also have integrated non-HIPAA-covered entities, and with those entities, there must be explicit client consent in order for any data to be shared at all. It's a big move because those clients, typically on the non-covered side have really struggled to pull information together.”
Iannuzzi said they sought to build a best-of-breed technology solution. “We really wanted to be able to bring these diverse data sets together and build standards around the way that data is exchanged. It's hard work because the data sets are so different. The clinical sets have been relatively easy to pull together, but when you start to bring in jail data, housing data, even social services data, the paradigm in which that data is collected and shared is very different,” she said. “We've also built strong privacy and security infrastructure, with the patient consent as an integral part of that relationship and allowing patients to consent to what can be seen.”
Alameda County Care Connect worked with a company called Thrasys to build the information exchange where data from physical health and behavioral healthcare systems, healthcare utilization data from health plans and social care data from the homeless management information system (HMIS), social services agency, and justice system are aggregated in ways that allow the county and its contracted providers to close gaps in the safety net to coordinate and accelerate care for a large number of the county’s most vulnerable residents.
They also worked with Collective Medical, which brings in real-time data feeds so that they could send alerts to care managers. In addition, they teamed with Verato for patient and client matching across all these sectors.
The community health record has a combination of elements, including client demographics and claims information. “We have added some real-time alerts, including inpatient and ED touches, knowing when somebody has entered the hospital, and when they have been released, and the same on the jail side, knowing when someone has been booked, knowing that they're still in jail and then more importantly, knowing when they've been released, which is one of their most vulnerable times,” Iannuzzi said. “Those are sent in real time to the care manager. They know where their panel of patients is in their crisis.”
The care team members are integrated a couple of ways — through messaging one another securely or through share documents, or they can communicate in a shared care plan. “That shared care plan, while not asking for a lot of duplicate information is really engaging in the client’s shared care, so that they're really only telling their story once,” Iannuzzi said. “We are also leaning in when there are moments of crisis where we can give tips on how to best approach a client when they're in crisis.”
Julie Silas, directing attorney for Homebase, said her organization has been studying how healthcare and homelessness systems in California have been working to share data.
She said there were clear benefits, including the ability to communicate and better coordinate care. It is allowing communities to be more strategic with their policy development and their analytics. It also results in administrative efficiencies, including cost savings, when you pull resources together, to collaborate on developing the systems.
Despite all of efforts to share data, there are real challenges to overcome. “We were able to see some common patterns in terms of the challenges that communities have faced,” Silas said. A lot of the issues dealt with privacy, she said, because you're looking at two different systems that have different privacy rules. Sometimes, knowing that there are different privacy rules creates a barrier in and of itself. “They're siloed systems. They haven't worked together before,” she said. There are also interoperability issues with the technology itself, and some of the housing and healthcare systems have not been modernized to be able to make data sharing more effective.
“There are a lot of different ways that communities have been able to bridge some of those gaps or to overcome some of those barriers to be able to do cross-sector collaboration,” Silas said, “and the impacts have had far-ranging effects on people's day-to-day experience.”
Now healthcare and social system partners are preparing for the January 2022 launch of California’s Medicaid reform program, California Advancing and Innovating Medi-Cal (CalAIM). The effort seeks to build on the successes of waiver demonstrations such as Whole Person Care, the Coordinated Care Initiative, and public hospital system delivery transformation. CalAIM will leverage Medicaid as a tool to help address many of the complex challenges facing California’s most vulnerable residents, such as homelessness, insufficient behavioral healthcare access, children with complex medical conditions, the growing number of justice-involved populations who have significant clinical needs, and the growing aging population.
