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Multi‐System Data Sharing to Support Whole Person Care
Sheilani Alix Operations Director Data Exchange Unit ‐ Alameda County Care Connect
Malcom ScottConsumer & Family FellowAlameda County Care Connect
Jennifer Pearce, MPASenior ConsultantBright Research Group
November 14, 2019
AcknowledgementsAlameda County Care Connect Leaders and Staff
• Kathleen Clanon, MD, Medical Director• Jennifer Martinez, MPH, Program Development Director
• Valerie Edwards, LCSW, Director of Clinical Case Management Methods
• Rebecca Alvarado, LCSW, Manager, Clinical Case Management Methods
• Bridget Satchwell, System Outreach Manager• Lillawa Willie, MPH, Delivery Oversight Program
Data Exchange Unit Leaders and Staff – C & C Advisors
• Cristi Iannuzzi, Director of Strategy & Implementation
• Cheryl Northfield, PMO & Compliance Director
• Rajib Ghosh, Director Social Health Information Exchange
Workshop learning goals1. Describe the benefits of cross‐system data sharing from the provider
and consumer perspectives2. Define key data sharing terms in order to help make the case for data
sharing.3. Evaluate a data sharing authorization form to determine if it is
readable, understandable and actionable for consumers.4. Understand the design and use of multi‐system, multi‐disciplinary
convenings that utilize this data to identify service and system gaps.
The Community Health RecordDesigning a cross‐system data sharing product that inspires trust among users
The Challenge
Consumers seek and receive care from a wide variety of organizations.
• The consumer is often the only person who knows about all the care and services rendered
• Without transparency, care efforts are poorly coordinated and often duplicated
Whole Person Care Pilot
SA10
Slide 6
SA10 Two new slides included (slides 7&8); maybe can replace this with those?Sheilani Alix, 9/18/2019
The imperative
Providers serving low‐income communities believe social needs are as important to address as medical conditions. Information about shared clients is transmitted by hand‐carried documents, by fax, by two way sharing, or (often) not at all.
Crisis Response
Medical Care
Housing
Social Care
Substance Use
Mental Health
Legal Services
We must move from fragmented, episodic care to transformative care.
Current state
Critical change: Data exchange• Created a data repository• Expanded and updated data sharing agreements
• Tested a prototype Community Health Record (pCHR)
• Created a Social Health Information Exchange (SHIE) and Community Health Record (CHR)
Medical Care
Mental Health
SubstanceUse
Services
HousingSocial Care
Legal Services
Crisis Services
Care Connect target population
Actively enrolled in Medi‐Cal (Medicaid) and …
• Experienced homelessness (last 2 years)
• Met frequent user criteria in at least 2 crisis systems (last 12 months)
• Enrolled in a comprehensive case management program
SA11
Slide 9
SA11 Changed "eligible" to read "target population". The eligibility criteria for AC Care Connect is very complex, but the primary target population remains these three key criteriaSheilani Alix, 9/26/2019
BENEFITS OF CROSS‐SYSTEM DATA SHARING
Consumer Perspective
• Improves care coordination• Faster connection to care and services
• Alleviates burden placed on consumer to recall and connect services
Provider Perspective
• Avoids duplication across consumer’s care team
• Makes it easier to connect consumers with primary care, social and housing services
• Reveals whole person needs, wants and preferences
Benefits of data sharing across systems
Data sharing relies on CHR + SHIECommunity Health Record(CHR)
• Electronic record application that summarizes curated information drawn from different care organizations
• Approved providers can see information from data sources serving the consumer and better coordinate care
Social Health Information Exchange (SHIE)
• The SHIE is the engine that powers the CHR
• Ingests data from external systems, like: Electronic Health Record (EHR), case management and claims
CHR/SHIE Data privacy managementUsers at participating organizations have access to data for AC Care Connect consumers who are “attributed” to their organization. Data is limited by organization type and consent choices.
• Access determined by:- Organizational attribution (medical home or
encounter)- Organization type mapped to
policies/regulations and consumer consent- User types (role‐based access standards)
• Universe of “consumers” = Care Connect eligible individuals
Term Definition
Data Sharing Agreement At organization level: A universal agreement that governs sensitive datasets inside and outside federal, state and local regulations
Information Sharing Authorization
At the consumer level: Identifying what can be shared, with whom it can be shared, and when it as expired or been rescinded as directed by the consumer
Data Warehousing A centralized data repository storing medical, mental health, substance use, housing, social care, crisis response, legal data reports and self‐service
Attribution Set of rules that determine what records can be accessed by a specific person; another way to control security and privacy
Key data sharing termsSA1
Slide 13
SA1 Not sure I understand how this particular selection of terms here will be presented (e.g., there's a little more tothe legal framework than just the data sharing agreement, etc.). It seems to be a mix of system functionality and operational policy. Depending on audience might have varying levels of relevance? Maybe we can talk through how this slide will be presented? Suggested other terms to include: Information Sharing Agreement, Shared Care Plan, Attribution, Data GovernanceSheilani Alix, 9/17/2019
CHR Wave 1 Participants Success depends on partnership
Data Feed into CHR• Alameda County Behavioral Health
(ACBH)• Homeless Management
Information System (HMIS)• Alameda Health System (AHS)• St. Rose Hospital • Clinics (Lifelong, Tri‐City, Tiburcio)• Health Plans (Alameda Alliance for
Health, Anthem Blue Cross) • Other Bay Area Hospitals
CHR Users1. Alameda County Behavioral Health (ACBH)2. Alameda Health System (AHS)3. Lifelong4. Tri‐City5. Health Plans (Alameda Alliance for Health,
Anthem Blue Cross) 6. Abode Services7. Bay Area Community Services (BACS)8. East Bay Innovations (EBI)9. Pathways to Wellness10.Alameda County Health Care Services
Agency – Care Connect and select Behavioral Health Teams
What is being shared
Curated, actionable information designed for inter‐agency and inter‐sector care coordination to promote real‐time action.
Client Demographics
Care Team Members
Encounter Information
In‐Patient / ED Encounter Reports
Shared Care Plan
Early impact on the consumer and provider experience
• Improved care continuity – gives providers the ability to locate hard‐to‐find consumers and meet them where they are (real time emergency department notifications)
• Improved care coordination – serves as a support tool during case conferencing
Stakeholder EngagementEnsuring consumers and providers are comfortable sharing information
Value of consumer engagement
• Gives consumers a say in what is shared• Promotes understanding when it comes to rights• Establishes a foundation for informed choice about information sharing
Consumer & Family Fellows
Information Sharing Authorization Form
The form is embedded in the CHR, but is also available in paper form for use in the field • The form must be signed in person by the consumer (electronically or on paper)
• The form is valid for 1 year after signing and can be revoked or changed by the consumer at any time
• It includes specific permission for sensitive services (i.e., HIV and mental health treatment)
https://vimeo.com/325618382Care Connect staff and Fellows discussing the Fellowship and the value of consumer input
Original
• Readability: grade level 16• Average sentence length: 28 words• Complex words: 159
Revised
• Readability: grade level 8• Average sentence length: 13 words• Complex words: 106 defined in plain language
A tale of two consumer experiences
Consumer and Family Fellow engagement
Health Literate
Understandable
Actionable
Readable
Examples of what changed as a result of consumer input
• Created a more comprehensive summary on page 1• Revised “If I don’t sign …” language to feel less threatening• Provided more detail about types of programs and services included
Added a concise summary at the top
• What we’re asking: The County of Alameda (the “County”) is asking for your authorization to allow sharing of your protected health information and other personal information (“information”)
• Why we’re asking: Sharing information makes it easier to see if you are eligible for resources
• You have a choice: By signing this form … OR If you do not sign this form …
Before: Dense Text
After: Health Literate Layout
Value of Provider EngagementEnsures providers from all sectors feel comfortable sharing information
Informs what information is most relevant
Provider Engagement
Health Care Services Agency: Care Connect, County Counsel, EMS,
Public Health
Health Plans Hospitals CBO Providers
SUD Providers Housing Human Services Sheriff
Probation Legal Services Drug Court
What changed as a result of provider input• Eliminated probation and sheriff from authorized organizations • Added jail health services and crisis response provider types• Included information sharing with (but not from) SUD treatment providers• Added that a list of included organizations will be printed for consumers• Changed “social” services to “human” • Added specifics (i.e., help desk number) for limiting information shared • Included clarity about option to change choice, at any time • Set a 1‐year expiration (vs. 5)
Multi‐System, Multi‐Disciplinary ConveningsUsing shared data to identify and bridge service gaps for people with complex needs
The Psychiatric Emergency Services (PES) Frequent Utilizers Pilot and Goals
1) To understand and develop empathy for the consumer’s experience across the care continuum by including representatives from a wide variety of organizations and disciplines; and
2) To illuminate system gaps to inform a more nuanced, human‐centered response to crisis care.
Continuum Case Conferencing and sharing data across systems• Highlights the consumers’ experiences navigating the system, revealing gaps that previously were evident only to those who fell through them
• Draws care and service providers out of their silos, fosters a sense of empathy for provider peers, and creates a shared responsibility for consumers’ experiences
• Creates greater system accountability for the gaps and informs policies and resource decisions to help close them
Who attends/systems represented
Community medical
Community behavioral health
Community housing and social service partners
Consumer and family advocates
Psychiatric emergency system
County Health Care Services
Agency
County justice system
What has improved or changed as a result
• Updated discharge protocols• Telephonic and in‐person follow‐up after psychiatric emergency room visits: Crisis Connect and Friendly Faces
• Community‐based assessments and disposition planning
Benefits of information sharing from the provider perspective
• Increased empathy for consumer and “whole person” picture• Sense of camaraderie with providers from other systems
• “I don’t feel alone working on these problems.”• “I feel hopeful to know others are work to change the system.”
• More complete picture of the consumer (non‐crisis state)• “A puzzle that’s becoming more complete.”
Read the Care Connect brief:Continuum Case Conferencing for an Improved Behavioral Health Systemhttps://www.nationalcomplex.care/category/research‐policy/resources/publications‐reports/
Sheilani Alix Data Exchange Unit Ops Director Alameda County Care [email protected]
Jennifer Pearce, MPASenior ConsultantBright Research [email protected]
What questions do you have?
