The Road to 360o: Community Coordination

1. Community coordination The road to 360o Monday May 22, 2017 Presenters: 9 Meg Storer 2-1-1 San Diego Bill York 2-1-1 San Diego Karis Grounds 2-1-1 San Diego Camey Christenson 2-1-1 San Diego

2. WELCOME and introductions

3. The road to 360o What’s our Route for the Trip? • The First Leg of the Trip: Curriculum Intensive • Why & Vision • Collective Impact & SDOH • 2-1-1 Role: Past and Future • 360o Community Coordination • The Second Leg of the Trip: Applied Implementation and Integration • Internal Needs Assessment • Creating Internal “LeapFrog” & Identifying Priorities • Charters & Change Management • Incorporating External Partners • Outcomes and Evaluation • Next Steps within your Community

4. WHY do you want an adventure?

5. The First Leg of the Trip

6. What goes into your health?

7. Health Paradox “The field of public health refers to the conditions that are not medical but that can produce or undermine health as the “social determinants of health.” These are the socioeconomic, environmental, and behavioral factors that research over many decades has shown to be strong influences on health.” Elizabeth Bradley, The American Health Care Paradox: Why Spending More Is Getting Us Less In the U.S., for $1 spent on healthcare, about $0.90 is spent on social services In the OECD, $1 spent on healthcare, about $2 spent on social services

8. U.s. health rankings

9. Collective impact

10. Social determinants of Health (sdoh) Social determinants of health are micro (small scale) and macro level (large scale): • Individual (age, gender, race, language) • Behavior and Choices (smoker, eating habits, exercise, drug use) • Access To (healthcare, housing, food security, employment) • Environment (sidewalks, parks, neighborhoods, public transportation) • Community/Politics

11. Impacts on Health Macro Policies Micro Dimensions Access To Family/ Individual Behavior/ Choices Neighborhood/ Environment Stable Housing Early Childhood Education Child Care Food Security Health Literacy Living Wage Jobs Technology Health Insurance Medical Care Utilities Language Disability Age Race Gender Culture Social Support Sexual Orientation Household/Living Situation Transportation Chronic Illness Education Employment Readiness for Change Eating Habits Alcohol/Drug Use Exercise Smoking Safe Sex Coping Skills Public Transit Sidewalks Parks Grocery Stores Quality Schools Quality Care Laws

12. Our Journey

13. 2-1-1 San Diego and our mission Our mission is to serve as a nexus to bring the community (organizations) together to help people efficiently access appropriate services, and provide vital data and trend information for proactive community planning.

14. 2-1-1 San Diego Who we are • 2-1-1 San Diego’s purpose is to make positive, lasting impacts on people’s lives and drive meaningful change throughout our communities. • 2-1-1 San Diego’s values: • Deliver WOW through Service • Embrace and Drive Change – Evolve • Create Fun and A Little Weirdness • Be Adventurous, Creative, and Open-Minded • Pursue Growth and Learning • Build Open and Honest Relationships with Communication • Build a Positive Team and Family Spirit • Do More With Less • Be Passionate and Determined • Be Humble

15. 2-1-1 San Diego Who we are 4,261 square miles (larger than 21 states) Urban and rural 5th largest county in the nation and 2nd largest in California 18 municipalities; 36 unincorporated areas 18 tribal nations 42 school districts Population – 3.2 million people Larger than 19 states 6 healthcare systems Busiest international border crossing in the world (San Ysidro/MX)

16. Programs and services • Enrollment Center • 2-1-1 Pioneered telephonic signatures for public benefit programs. • Has submitted more than 30,000 applications for CalFresh, Medi-Cal and Covered California. • Military and Veteran Services • 2-1-1 answers the Courage to Call peer-to-peer helpline offering care coordination as the single point of access for veterans, active military, reservists, national guards, and their families. • Health Navigation • Provides care coordination addressing health and social aspects of the whole person to clients with complex needs, under/uninsured

17. Enrollment Services • San Diego CalFresh Applications • San Diego Medi-Cal Applications • San Diego Covered CA Applications • San Francisco County CalFresh Applications • Imperial County CalFresh Applications • Targeted Outreach projects with San Diego County with current Medi-Cal recipients for re-certification and CalFresh outreach

18. Military and veteran services Collaborative Partnership Mental Health Systems Veterans Village of San Diego 2-1-1 San Diego Prevention and Early Intervention (PEI) program Funded by the County of San Diego, Health and Human Services Agency (HHSA) Serve as the contact hub for all military, veteran and their families San Diego County Offering a deeper level of care with a case management option.

19. Health navigation Health Navigation serves as a single access point for anyone in need of health services, addressing the health and social needs of the whole person by better connecting, empowering, educating, and advocating for clients with health needs. Target Populations: Clients experiencing issues with accessing care, managing chronic conditions and uninsured /underinsured. Goal: Address risk factors and social determinants of health to help clients achieve a better quality of life and health outcomes. Care: Complete an in-depth holistic assessment and establish a care plan to address the needs of each client. Continual follow ups: To address and monitor progress of each client and create a foundation of support by connecting clients to community partners.

20. 2-1-1 past and future

21. How we measure success Past Future • Wait Time • Average Talk Time • Abandonment Rate • Average Speed of Answer • Number of Referrals • Confidence • Self-Sufficiency • Connection & Outcome of Referral • Change over time

22. Approach to care

23. Siloed systems

24. Regional information exchange

25. 2-1-1/CIE Trust Network Partners Healthcare:Emergency Services: Scripps Mercy Hospital AMR/Rural Metro Ambulance Family Health Centers of San Diego City of San Diego Fire/Rescue Molina Healthcare Homeless Service:Senior Services: Alpha Project ElderHelp PATH Serving Seniors St. Vincent De Paul Village Meals-on-Wheels Catholic Charities HMIS Regional Provider: Regional Taskforce on the Homeless

26. Evaluation results: community information exchange 26% reduction in mean number of EMS trips pre and post CIE enrollment for 233 CIE enrolled clients with a history of EMS use. Largest percent reduction (42%) for clients with highest EMS risk 38% reduction in the percentage of housed clients who exited housing and went back to the street (24% vs 15%) between those that were not looked up compared to those that were looked up. Largest effect seen among clients with EMS history (62% reduction). 44% improvement in percentage of housed clients who remained in current housing placement between those who were not looked-up and those who were looked up. Largest effect (77% improvement) seen among clients with EMS history.

27. 360o Community coordination Improve clients health and social functioning by: Establishes a longitudinal shared client record Increases access through electronic bi-directional referral system Utilizes shared tools, language, assessment, and outcomes Addresses holistic clients needs (social determinants of wellness), past and current referrals and outcomes Offers service providers access to meaningful data based on shared measurements

28. Internal and External Re-Engineered Internal Case Management vs. Call Center Outcome Measures vs. Call Metrics Integrated Processes vs. Program Processes External Shared Outcomes vs. Silo Outcomes Community Care Plan vs. Agency Care Plan Proactive Referrals vs. Passive Referrals

29. Technology Architecture

30. elements of 360o 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 • Agencies or programs client is referred • Ability to note barriers to accessing referral

31. elements of 360o shared record • Program Enrollment • Agencies or programs client is receiving services • Status of service or program • 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

32. Domain Comparison

33. Methodology for 2-1-1 SDOH • Identify Current used SDOH • WHO (HealthyPeople2020, Live Well San Diego, Centers for Disease Control, Kaiser Family Foundation, Alliance for Information and Referral Taxonomy (AIRS) • Outline Impact on Community Level • Individual, Behavior & Choices, Access To, Environment, Policy • Based on Micro (Client/Family) vs. Macro (Environment) • Measure Impact (Risk Rating Scale) • Change over Time (Self-Sufficiency Model JFS) • Crisis, Critical, Vulnerable, Stable, Safe, Thriving

34. Methodology for 2-1-1 SDOH • Identify Shared Measures through Assessments & Domain Standards • Evidence Based Tools & Social Service Intake • Risk: Immediacy, Barriers, Complexity, Protective Factors • Situational: Demographics, Socioeconomic Status, Associated • Feedback & Integration • Review & Feedback Session with Agency Subject Matter Experts • Integrated Intake • Shared Measures, Values Across Agencies & Eligibility Criteria • 25 different agencies • Validity-USD Caster Center • Point Based Values • Matching value to responses based on literature & risk • Objective vs. Subjective • Calculation of change over time

35. Screening VS. Assessment • SOCIAL SERVICES PROVIDERS • Priority: • Addressing complex and interrelated dynamics • Secondary: • Accounts for relationship between health and social • Example: • What is your current health situation? • Open ended (Physical, Mental/Behavioral, Substance Abuse, Dental) • Are you experiencing any barriers to managing your health condition? • Transportation, Prescription Costs, Health Insurance Issues, knowledge health condition, procedure costs, timeline for care, medical equipment • What types of services are you hoping access to help you? • Medical home, Sobriety Services, Inpatient, Medical Access, Financial Assistance Programs, Medical Home • HOSPITALS • Priority: • Providing Medical Care • Secondary: • Screening for Specific Social Risks • Example: • What is your housing situation? • Have housing, I don’t have housing, I choose not to answer • What is the highest level of school that you have finished? • Less than high school degree, High school diploma, more than high school, I choose not to answer

36. Risk rating scale

37. What is HIPAA? Health Insurance Portability and Accountability Act - a 1996 Federal law that restricts access to individuals' private medical information

38. Tier 1: Referral Partner • Agency listed in the searchable 2-1-1 database • Login access to update community profiles and add services • Agency information provided by 2-11 staff to clients • Request reports on referrals to you agency

39. Tier 2: Connected Partner • Direct client referral from 2-1-1 call center staff, by sharing basic client information • Agency ability to accept or return referral • Option to provide additional feedback on client outcome • No access to 2-1-1 360o client profile

40. Tier 3: Integrated partner • Ability to access 360O client profile in CRM • 2-1-1 sends client referral and agency access to client profile • Agency ability to accept or return referral and provide feedback and outcomes • Agency can also consent clients into 360o CRM • 360o CRMfor shared clients • View only options

41. Future Opportunities Tier 4: Organizational partner • Utilizes 360o CRM for agency’s own program operations with administrative rights • Can send referrals to other agencies, using the customize the 360o CRMplatform • Customizable fields based on agency needs

42. Future Opportunities Customized partnership • Formal partnership between agency and 2-1-1 to provide specified care coordination for an agency’s clients • Customized assessment and outcome measurements

43. 2 1 31 44 5 6 ONE: Service Check Internal needs Assessment SIX: Destination reached Next steps within your community TWO: Road team & List of sites to see CreatingInternal Leapfrog & Identifying Priorities THREE Checking the map & making detours Charters & Change Management FIVE: Checking your street cred Outcomes and evaluation FOUR: Recruiting more road warriors Incorporating external Partners

44. The second Leg of the Trip

45. But First… Go.voxvote.com PIN: 44178

46. 1 One: Service Check (Internal Needs Assessment) ONE: Service Check Internal needs Assessment

47. Group Discussion: What areas of your own organization are most successful? What areas will be most challenging?

48. 2 1 TWO: road team and list of sites to see ONE: Service Check Internal needs Assessment TWO: Road team & List of sites to see CreatingInternal Leapfrog & Identifying Priorities

49. Group Discussion: Who within your organization could be part of your leapfrog team? What are their skillsets? Who is the visionary leader within your org?

50. 2 1 31 THREE: Checking the Map and Making Detours ONE: Service Check Internal needs Assessment TWO: Road team & List of sites to see CreatingInternal Leapfrog & Identifying Priorities THREE Checking the map & making detours Charters & Change Management