1 Community Information Exchange Kickoff Meeting May 7, 2019
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Community Information ExchangeKickoff Meeting
May 7, 2019
HealthierHere is a Non-Profit Organization
Dedicated to improving the health and well being of people in King County, through innovative, cross sector collaborations. We work…
in partnership and collaboration with providers and community organizations
on behalf of people here, especially the most vulnerable
to catalyze and test new and better ways to respond to health and social problems
so that the system can work better for everyone
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A Connected System of Whole-Person Care
No matter where people enter thesystem…
they receive the appropriate care and community supports to live healthier lives.
System is more cost effective and sustainable.
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Our Region Needs a Broader Collaborative Approach
To improve the health of people in our community, we must effectively address the social determinants of health.
20% Clinical Care
10% Physical Environment
20% Health Behaviors
40%Socio-Economic Factors
Clinical care represents only 1/5 of the factors that impact health outcomes.
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Challenges and Needs Identified by Clinical Partners
We need better linkages with jails. Jail can escalate behavioral health issues.
Behavioral Health Agency
Engagement can be challenging –primarily due to homelessness and lack of resources. Unfortunately, it sometimes takes an Emergency Department visit for us to get their latest contact information.
Behavioral Health Agency
Some patients do have not caregivers at home nor resources to obtain them. Some do not have safe and affordable housing. Some need a nursing home, but none will accept them.
Hospital
We need more resources for outreach –care coordination and navigation.
Federally Qualified Health Center
HIPAA guidelines prevent some cross-sharing of information from the clinical side to the non-clinical side.
Behavioral Health Agency
Lack of community resources. Specifically, housing, supported housing, wrap-around services, continuum of care.
HospitalOur biggest barriers are not knowing that the patient has been discharged, inadequate provider to provider coordination, lack of appropriate medical records, lack of knowledge about the care plan, lack of clearly defined social support.
Federally Qualified Health Center
Lack of feedback loop on: a) whether patient followed up, b) whether care provided was adequate, c) whether there were additional opportunities for better transitions.
Hospital
Supportive services for housing, employment, food, and access to care for transportation and language.
Federally Qualified Health Center
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Long-term: What Success Looks Like
Computer systems that talk to each other to improve Community/Clinical connections
Care teams that are representative, culturally competent and respectful of individuals and community.
Meaningful mechanisms for community and consumer voice that help drive decision-making for healthcare
Payment models that compensate providers for keeping people healthy (rather than #’s of procedures) and Community-Based Organizations for contributing to better outcomes
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Strengthen Foundational System
Infrastructure and Capacities
Co-Design System-Wide Tools to Enable
Integrated Community &Clinical Care
Convene clinical and community partners to co-develop blueprints for system-wideintegrated care:
Shared Care Planning: Convene partners to define data elements, develop workflows,implement pilot(s), identify technology to scale and sustain
Standardized Social Determinants of Health (SDOH) Screening:Convene partners to provide SDOH screening tool recommendations and sample workflows
Community Information Exchange System (CIE): Convene partners, experts and investors on how best to develop and fund
Support system-level data integration and analytics: Co-develop system level data set/system and evaluate analytics tools
Co-Design Systemwide Tools to Enable Integrated CareCatalyze & Test
Cross-Sector Innovations to
Improve Outcomes
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ImprovedOutcomes and
Lower Costs
• Healthier, more engaged community• Value for money and economies of scale• Data for proactive planning and investing
Community and Health Service Providers
System
Consumers
• More complete history of individual• Better coordination across sectors• Reduced duplication of effort• Data to measure and improve success• One coordination system to learn and use
• One-stop shop• Efficient access to services• Visibility to program
requirements
Benefits of a CIE
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HealthierHere and the Medicaid Transformation Project
– 26 member, multi-sector Governing Board
– Building strong partnerships with health, behavioral health and community-based organizations
– 27 Clinical Practice Partners
– 55 Community Innovation Partners
– Foundational values around Equity and addressing Social Determinants of Health
– Dedicated resources to convene around CIE and help start up
Multiple organizations and initiatives in the region interested in similar solutions
Our Opportunity
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Determine if there is shared vision amongst and across organizations and initiatives in King County seeking to create improved mechanisms to identify and link individuals to the services and supports they need thru technology
– Community Information Exchange is a potential solution to meet shared goals
Achieve agreement (in principle) that the organizations and initiatives should collaborate together on establish an integrated Community Information Exchange for the region, rather than each one doing their own thing.
Goals For Today
Ice Breaker Activity
Ice Breaker Activity
• Name• Organization• What is your WHY?
Briefly, in 1-2 sentences, reflect on what brought you to your career, your organization, or this meeting.
Designing Systems Change: Transforming the CommunityJohn Ohanian, President & CEOKaris Grounds, VP of Health and Community ImpactBeth Johnson, Director of Strategic Initiatives
2-1-1 San Diego / Imperial• Free, 24/7 service, 3-digit
dialing code• Access to community,
health, social and disaster services
• Tailored programs take the client beyond just a referral—movement towards Navigation
Community Information Exchange• Systems change that fosters true
collaboration across networks• Moving towards person-
centered interventions and interactions across healthcare and human services
• Goal is to improve health and wellness for individuals and populations
State of the Field
Proliferation of Technology
Public Awareness of the Social
Determinants of Health
Evolving Funding Environment
Person-Centered Care
Cross-Sector Collaboration
Research and Policy Advocacy
State of the Field
Public Awareness of the Social Determinants of Health
Social Influences Greatly Impact Health
Hood, CM, Gennuso, KP, Swain, GR, & Catlin, BB. (2015). County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine.
Person-Centered Care
Innovations in technology have
fundamentally transformed how
people consume, use, and share
information.
Proliferation of Technology
Cross-Sector Collaboration
Increase in cross-sector collaboration to break down
silos and foster clinic-community linkages to better
understand and serve the needs of people who
overlap systems of care.
Evolving Funding Environment
Increase in efforts to measure whether investments in health care and social interventions impact a person’s health and well-being relative to the investment.
Research and Policy AdvocacyData has been instrumental in shaping public policy to reinforce cross-sector collaboration and the role of social determinants of health on quality of life.National research and collaborative network initiatives provide an avenue for local collaborative to examine their impact on population health across
• socioeconomic class, • demographics, geographic areas, and • patterns and trends that influence human
behavior.
What is a Community Information Exchange
A community information exchange (CIE) is an ecosystem comprised of multidisciplinary network partners that use a shared language, a resource database, and an integrated technology platform to deliver enhanced community care planning. Care Planning tools enable partners to integrate data from multiple sources and make bi-directional referrals to create a shared longitudinal record. By focusing on these core components, a CIE enables communities to shift away from a reactive approach to providing care toward proactive, holistic, person-centered care.
Core Components of a CIE
Community Information Exchange PartnersNetwork Partners
Healthcare SectorHealth Plans
Hospitals
Emergency Medical Services
Health Centers
Health Information Exchange
Behavioral Health
Public Health
Network Partners
Social Services SectorHousing
Multi-Service
Human Development and Aging
Legal
Employment
Nutrition
Network Partners
Government
• Roles of Cities and County
Network Partners
Primary Care and Prevention
Housing Stability Health Management
Nutrition & Food Security
Legal & Criminal Justice
Safety & Disaster
Transportation Employment Development
Personal Care & Household
Goods
Financial Wellness and
Benefits
Education & Human
Development
Social & Community Connection
Activities of Daily Living
Utility & Technology
14 Domains: Risk Rating Scale
CRISIS CRITICAL VULNERABLE STABLE SAFE THRIVING
KNOWLEDGE AND UTILIZATION
BARRIERS AND SUPPORTS
IMMEDIACY
Shared Language
(SDoH)
Resource Database and Bi-directional ReferralsBidirectional
Closed Loop Referrals
• Shared taxonomy language for referrals (AIRS)
• Dedicated resource staff• Standards to listings and
requirements• Inclusion/Exclusion Criteria• Linked to health conditions • Tracks resource availability
and unmet needs
Technology Platform
ETL
API
Housing (HMIS)
EMS
API
Extract Transform Load1. Reads data from a database2. Converts the data for the new database3. Loads into the new database
MDMMaster Data Management• Detects and merges duplicate records• Ensures the accuracy, completeness, and consistency of
multiple domains of enterprise data
API
shared client record
CIE
File upload
Alerts
Single Sign on
Jail
Food
!
Technology Platform and
Data Integration
CIE Shared Record
• Client Profile• Demographic and important
information about the client• Domains
• Examples like Housing, Food & Nutrition,
• Categorization of Needs (SDOH) & Risk Level
• Shared Assessments and Values across agencies
• Care Team• Case Managers working with
client across agencies• Contact Information
• Referrals & Program Enrollment• Agencies or programs client is
referred• Connection to Services
• Alerts• Notification of emergency
services & jail• Ability to notify Care Team
Members of changes• Feed
• Ability to communicate like Twitter to other Care Team members
Community Care
Planning
CIE Shared RecordCommunity
Care Planning
Benefits of a CIE
Potential Value and Alignment
Healthcare Justice-Involved
Education Public Safety Employment Utility and Technology
Data Research Sel f Serv ice
Opportunity: Without addressing whole
person, health outcomes will not
completely improve for all
Target: Health Plans, Hospitals, Health Centers/Clinics
Impact: Improve Patient Health
Outcomes
Value: Revenue structure to support
approach and intervention
(readmission, value based care, healthier
members)
Opportunity: Lack of early intervention and wrap-around
services for children, families and students
Target: Adverse Childhood Effects,
Violence, Foster Youth, Colleges
Impact: Coordinated
supports for families and service
providers
Value: Reduction in Absenteeism
(increase funding for schools), Graduation
Rates
Opportunity: Poor prevention, release and racial inequities
Target: Parole, Re-entry, Recidivism
Impact: Early connections can
prevent arrests and support post-
incarceration with whole person care
Value: Reduction in government spending by
decreasing jail recidivism
Opportunity: Increasing
incidences of violence and disconnected
prevention and support resources
Target: IPV, Gun Violence,
Neighborhood Safety
Impact: Early intervention
resources to link individuals and families in crisis
Value: Local capacity to prevent
violence and support communities
Opportunity: EAP programs, to
support personnel, family and workplace
Target: Workforce Development, Government
Impact: Ability to access resources
and supports to be successful in work
Value: Healthy, happy and
productive workforce
Opportunity: Technology divide
Target: Cell Phone Carriers/Plans, Apps
Impact: Improve access to resources
and information
Value: Communication and connected to needs
to target markets
OPP
ORU
TUN
ITY S
TREA
MS
Reduction on healthcare utilization
Improvement in social and health
wellness
Better Health OutcomesImproved
Efficiencies in connection and relationship to
resources
Evidence for Success
R e c o r dL o o k - u p s D i r e c t R e f e r r a l s
Ou
tpu
ts
S h a r i n g D a t a C o n s e n t s
I m p r o v e d i n d i v i d u a l ’ s s t a t e o f w e l l n e s s
Ou
tco
me
s C h a n g e f r o m d o m a i n s p e c i f i c
w o r k t o w h o l e p e r s o n c a r e
C h a n g e i n i n t e r v e n t i o n a n d i n t e r a c t i o n w i t h p e o p l e h e l p i n g
p e o p l e
I m p r o v e m e n t i n H e a l t h I n d i c a t o r s
Imp
ac
t
A d v a n c e Q u a l i t y o f L i f e
A d d r e s s i n e q u i t i e s ( R a c e , G e n d e r , C y c l e
o f P o v e r t y )
Questions?
Working Lunch: Defining a User Story
User Stories
JakeA Veteran
Story
MichelleA Child and Family Story
SamAn Older
Adult Story
SummerA Complex Care Story
Shared Visioning ExerciseBeth Johnson, Director of Strategic InitiativesKaris Grounds, VP of Health and Community Impact
Benefit and Impact• How will the establishment of a CIE
benefit individuals?• How will it benefit providers?• How will it benefit the greater
community?• How will it inform community
planning?• What will we do to ensure we are
moving towards health equity?
Technology
• What existing technological infrastructure can be leveraged across partners?
• What are the existing vendor relationships?• What types of software and platforms are
currently being used and in what way?
Stakeholder Engagement and Representation
• What is the value proposition for key sectors to be involved?
• Who are the stakeholders?• What are their roles? • Who should be at the
table?• Does your composition of
partners represent the various populations that you are trying to reach?
Data and Metrics• What existing data infrastructure can
be leveraged in King County?• What data, measures, and metrics
are currently being collected across partners?
• What CIE data, measures, and metrics should be collected to track success over time?
• How can we leverage CIE data to demonstrate ROI?
• How will a robust data infrastructure drive sustainability efforts?
The King County Vision
How do you see working across health and social sectors improving people’s lives in King County?
LAY IT ON THE LINE
ALL IN STILL HAVE QUESTIONS
NOT A PRIORITY At
THIS TIME
What is your level of commitment (in principle) to work collaboratively toward a Community Information Exchange?
Introduction to Feasibility and Co-creating a Path Forward Karis Grounds, VP of Health and Community ImpactBeth Johnson, Director of Strategic Initiatives
Approaches to Shared Stewardship
Sector Representation
• Representation across 14 social determinant of health domains
• Shared CIE Vision
• Champions and Early Adopters
• Partner Communication
Legal Framework and Considerations• Health Insurance Portability and
Accountability Act (HIPAA) and other confidentiality laws
• Protected Health Information (PHI)
• Federal compliance on use of personally identifiable information (PII)
•• Create a legal team
• State policies that might shape the legal framework
Data Needs and Technological Assets
• Existing data infrastructure
• Data, measures, and metrics
• Data asset map
Care Coordination Needs/ Challenges
• Care coordination needs and challenges
• Leverage user stories
Sustainability, Evaluation, and Return on Investment
• CIE benefit and impact
• Early wins for sustainability
• Addressing needs and new challenges
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Closing and Next StepsSusan McLaughlin
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ImprovedOutcomes and
Lower Costs
• Healthier, more engaged community• Value for money and economies of scale• Data for proactive planning and investing
Community and Health Service Providers
System
Consumers
• More complete history of individual• Better coordination across sectors• Reduced duplication of effort• Data to measure and improve success• One coordination system to learn and use
• One-stop shop• Efficient access to services• Visibility to program
requirements
Benefits of a CIE
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CIE Work Areas
Shared Stewardship
Shared Vision
Stewarding Entity
Community Engagement
Sector Representation
SDOH Domains and
Organizations
Early Adopters
Partner Communications
Legal Framework
Standard Patient Consent
Protected Health Information (PHI),
HIPAA
Personally Identifiable
Information (PII)
Roles and Permissions
Standard Security and Privacy Measures
Inter-Agency Agreements
Data & Technology
Data Systems and Information Sharing
Environment
Current and Future Technology Needs,
Requirements
Technology Selection
Care Coordination
Needs and Challenges
User Stories
Sustainability
CIE Value Proposition
Investment and Ongoing
Operation Costs
Business Model
Summarized from CIE Toolkit, 2-1-1 San Diego
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Learn• Other CIEs• Local Landscape• Partner Priorities
Define• Long-term Vision• Roadmap• Starting Point / Pilot
Design• Test/Pilot Plan• Resources• Budget for Start-Up
Steps to Explore a CIE in 2019
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Example Multiyear CIE Roadmap
2019 2020 2021
• Learn• Define• Design and Plan
Test/Pilot
• Run Test/Pilot• Select Technology• Plan and Budget
Scale-Up
• Scale-Up• Strengthen
Business Model
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Next meeting: June 27 at the Seattle Foundation
In the next couple of weeks, we will send a request of each of you to gather more specific information regarding your organization and/or initiative interests and focus:
– Current CIE assets and priorities
– Resources to participate in workgroups (e.g., vision & governance, community network, legal framework, technology, sustainability)
– Interest and capacity to pilot in 2020
We will shape our June 27 agenda using this information and today’s discussion to accelerate alignment and planning
Next Steps
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Thank You!
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