The State of California is piloting an ambitious effort called “Whole Person Care” within its Medicaid program by working with counties to coordinate health, behavioral health and social services. Twenty-five counties are starting to share data and coordinate care for vulnerable Medi-Cal beneficiaries who have been identified as frequent users of multiple systems and who continue to have poor health outcomes.
Underpinning these efforts are the technology solutions that will allow previously siloed organizations to share data, create shared care plans and evaluate individual and population progress.
Mark Elson, executive director of the San Joaquin Community Health Information Exchange, said the pilot program is challenging the safety net delivery system to coordinate services and requiring data sharing across sectors, including housing organizations and jails.
Elson leads the San Joaquin Community HIE, and his Berkeley-based consulting firm, Intrepid Ascent, also works with five other counties to implement IT systems to support data sharing for Whole Person Care. “We are doing an assessment for the California Health Care Foundation on IT models across all of the pilots,” he said. A report is expected to be published early in 2019.
San Joaquin Community HIE and the Marin County pilots have both begun working with ACT.md, a provider of healthcare collaboration software. ACT.md says its social health information network will support intensive care management, referrals between healthcare and community organizations, and community-wide care planning and task sharing processes.
Elson noted that in many of the counties, community-level HIEs are starting to take off, but they were not built to meet the needs of Whole Person Care. “Along with the requirements for care coordination across sectors, there are requirements for shared care planning for high-risk, high-cost Medicaid beneficiaries, many of whom are homeless,” he explained. Every individual must have a shared care plan created within 30 days of enrollment in Whole Person Care. “If you think of EHRs as providing the historical clinical record, and you want that to be available across organizations through HIE, there is still a gap,” he said. “Most HIEs don’t enable care teams to collaborate on future-oriented goals and planned interventions. Act.md and other care management vendors have jumped into this space and are performing a critical role.”
San Joaquin and Marin counties chose ACT.md because it has a strong user interface and because the platform supports the creation of care teams that include people from multiple sectors, Elson said. “They can set permissions so that a housing coordinator has access to an appropriate level of data based on the policy and legal framework,” he said. “They also have strong interoperability chops. That is important because part of the implementation in these two counties involves integration with the local HIE.”
Based on the procurements his firm ran for the two counties, he said, the data-sharing capabilities of care management vendors are quite variable, but there are a handful that have the ability to integrate with HIEs or EHRs. The challenge, he added, is being able to pull in a curated clinical data set rather than creating a massive data repository. “They just want to get actionable information to people actively engaged in care management across organizations, which makes them complementary to HIEs,” he said. “We’re seeing a similar approach in Santa Cruz County, for instance, with the Santa Cruz HIO bringing the care management vendor CrossTX to the table to support Whole Person Care and similar programs. And Alameda County, where there’s not a pre-existing community HIE, has selected a vendor, Thrasys, that does care management, HIE, and analytics all under one roof.”
A longer-term goal involves pushing some of the social data that will be generated in Act.md back into the partnering clinical systems via the HIE. “There is no consensus yet on what social data is helpful for clinical providers to receive back in their own system,” Elson said. “We are exploring making Act.md’s user interface accessible from specific partners’ EHRs so clinicians don’t have to make that decision about what data elements they want coming back.”
