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Beyond Coordinated Entry:Expanding enhanced information and referral beyond the bounds of a single system
Norris Brown, ServingLynk Bob Russell & Javier Celedon, Community Technology Alliance Eric Jahn & Sonia Kim, Alexandria Consulting
ask a question during the presentation: goo.gl/slides/wd78dg
Presented May, 2017 at the AIRS Conference in Tampa
the big ideaWe’re not here to show you a product, a system, or a specific tool to deploy.
We’re going to show you a replicable way of turning your community I&R, eligibility determination, and program enrollment into community-wide multi-system workflow.
This simplifies things by separating features and responsibilities, and avoids having “all your eggs in one basket”.
“Walled garden” high price per user systems.
Question: “How do we build something better for the community?”
● Community controls the data, keeps the warehouse● App interfaces can come and go● Our strategy: we just want to be the best host possible
in this ecosystem: charges based on data usage
How we got started on this
The collaboration
● community customers● ServingLynk: HSLynk● CTA: HOME App and analytic tool support● Alexandria Consulting: Project/Technical Consultants● analytic tool vendors● open source hmis/ces groups (starting)
Chat with us on slack: https://goo.gl/TPmNID
Why this is different?● Collaborative ● Modular● Not just about our system: anyone wanting to change
the status quo needs to address these issues● Community owns its data - “app neutral” open system● Coordination between systems, not a zero-sum
scenario where one funding stream’s system is selected: everyone continues to use their existing case management system
Why this is different (continued)
● Open Source ● APIs: “Open System”, like Facebook or Slack● Community can keep adding new schemas, all linked
by a Master Patient Index keeping one global ID per client
● Big Data - Analytics - bring your own tool (Tableau, Looker, Qlik, Crystal Reports, etc.) and connect to the warehouse
Why open source and why a warehouse?
● A data warehouse separate from the apps gives the community the ability to ultimately control its system and access to its data.
● The warehouse can talk to any system that can talk to the web.
Concepts that we want to elaborate upon...
Open Source - What is it and its benefits to the I&R community
Open APIs -What is it and why is it crucial in CES
Open Systems - Facebook and Google - they don’t dictate how you access them. This has nothing to do with Open Data, which is up to the community, and which we support.
Correlations between Definition of CES - Enhanced I&R/Eligibility Screening/Case Coordination
Opportunities for the I&R Community
● HMIS (Homeless Management Information System) coordinated entry system (CES) - Coordinated entry as vaguely defined by HUD is narrow: in practice, it typically consists of matching clients to HUD housing programs.
● Why not use it for any human services?● CES in relation to the I&R Community
○ Enhanced I&R○ Eligibility screening & case coordination
Opportunities for the I&R Community (continued)
● Existing service efforts: vendors and nonprofits provide solutions, but they are either not ○ automated or○ integrated with the community, or ○ replicable, or○ affordable
Opportunities for the I&R Community (continued)
Center for Medicaid Services -CMS’ Accountable Health Communities -32 participants serve as ‘hubs’ linking clinical and community services... addresses critical gap between clinical care and community services…through screening, referral, community navigation services” -https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-04-06.html
CES Opportunities for the I&R Community (continued)
HMG - Help Me Grow-The Help Me Grow system is designed to help states and communities leverage existing resources to ensure communities identify vulnerable children, link families to community-based services
-https://helpmegrownational.org/affiliates/
Current
Future
Additionally, each resource provider can manage its own matching, instead of the warehouse managing it centrally. Then, the warehouse is just for reporting across the system, and keeping the master index of clients.
Master Patient Index and Supporting Many Schema
● Different schema comply with specific regulations and requirements for each funding stream, instead of trying to impossibly make a single schema that can adapt to all requirements
● HMIS, for example, changes every year, changing logical relationships, and not just renaming data elements, so we can keep each version separate unless the data standard is clear about migration forward
● The global id binds all the records together
How does a Master Patient Index Work?
HSLynk Current Ecosystem
Modular and Expandable from the ground up.Our tools need to…
● Solve the problem● Be user friendly● Be Modular● Allow growth
● Monterey example - returned a year later and asked for a health information exchange
Bottom Line, we do not want to replace a system, we want to help a community do everything it needs to do by connecting separate data systems and producing a single source of truth
Data Sharing and Consent
● Release of information, APIs● Sharing between programs, agencies, if there is
consent to share● Uploading consent docs
HOME Homeless Outreach Mobile Engagement App
We started with a simple idea: create an open source mobile app
We then selected a community (Monterey/San Benito) to test and deploy HOME as part of their coordinated entry system.
Next phase: integrate with Whole Person Care (WPC).
CARS & WPC
Identify 500 high-utilizers
Match high utilizers to available housing and support services
Add open-source Information and Referral System functionality to HOME
Homeless CoalitionMission is to eliminate homelessness in Monterey and San Benito Counties by promoting interagency coordination to develop and sustain a comprehensive system of housing and support services designed to maximize the self-sufficiency of individuals and families.
Whole Person CareThe overarching goal of the WPC is the coordination of health, behavioral health, and social services in a patient-centered manner with the goals of improved beneficiary health and wellbeing.
WPC Issues and SolutionsHow do we share information?
Why not use Medical’ provider system?
How do we protect a client’s privacy?
How do we effectively case manage clients?
What are the necessary changes for CARS?
We are API Based, we share data through APIs
Not built for Human Services, square peg, round hole.
We have a Consent API that allows segregation of data based on ROIs collected and user credentials
Building support for case management. We are doing this in HOME, but could easily be done in any other system.
None, our modularity and flexibility our implementation of WPC allows CARS users to keep their existing workflow.
Data analysis, pathways to successful outcomes
70% of clients that have received services in Monterey county were successful after 1 stay.
We typically partner with other nonprofits such as Code for SF (Code for america) to work on data analysis.
Identifying other factors (data from other systems) gives us a more complete picture
Data analysis helps guide policy and decision within the community
Demo of HOME App
How we’re working with the open source community
● Code for SF● Impact Lab● Other Open HMIS-related individuals and groups - at
API level● Public Github code sites
○ https://github.com/servinglynk/hmis-lynk-open-source-docs/wiki○ https://github.com/hserv/coordinated-entry/wiki○ https://github.com/ctagroup/home-app/wiki
Contact us
Norris Brown, President [email protected]
Bob Russell, CEO [email protected]
Carl Treleaven, Founder [email protected]
Sonia Kim, Project Manager [email protected]
Javier Celedon, Operations Director [email protected]
Eric Jahn, Data Architect/IT Director [email protected]
Chat with us on slack: https://goo.gl/TPmNID
