Caboodle data warehouse5/17/2023 ![]() There is a variety of electronic health records systems on the market today. “This warehouse includes data from social services and the Homeless Management Information System.” “Contra Costa Health Services also connected Epic and other systems with the county-managed data warehouse in order to develop more comprehensive predictive models,” Crosby explained. This enables their caregivers to collaborate across disciplines to address patients’ full spectrum of needs. By integrating support for behavioral health and social needs within Epic, patients have one centralized record that incorporates key factors that affect their physical health and well-being. It was also used to extend Epic into the social case management program. “Part of the funding from the WPC program was used to extend Epic to behavioral health in order to include outpatient psychiatry care in the shared health record.” ![]() “Contra Costa Health Services originally implemented Epic in 2012 across its ambulatory clinics, hospital, detention health program, health plan and parts of its public health program,” Crosby recalled. The Epic EHR has been used as the record system at Contra Costa Health Services for more than seven years, and the WPC program included a rollout of Epic to new types of care settings in order to create a comprehensive record for patients. ![]() “Areas of focus in the pilot have included using data to automate time-intensive processes, sharing data with a more diverse range of partners, and equipping frontline workers with data to target and improve the services they provide.” “Contra Costa Health Services was awarded $200 million over the duration of the grant from 2016-2020,” she said. This involved bringing siloed divisions into the central data landscape through expansion of the existing Epic infrastructure where possible, and where not, improving the technology and integrating into a centralized data warehouse, Crosby added. ![]() “As the primary backbone to support this and the other grant aims, Contra Costa Health Services also applied for significant funding to expand and better utilize the existing data systems in place.” “Contra Costa Health Services capitalized on the opportunity to develop a large-scale social case management program for high utilizers of multiple systems,” Crosby explained. In fact, the WPC program estimates that automating the work required to determine a client’s eligibility and enroll them in the pilot has saved nearly 350 administrative hours per month." "Reducing the amount of manual work related to enrollment has not only made the program more scalable, but also freed up resources to reallocate to direct client services and case management. In screening for social needs in Contra Costa Health Services clinics, 50% of patients queried had one or more social need, including food, housing, health, utilities, employment, transportation, child care and education. The county’s low-income and vulnerable residents were disproportionately suffering from poor health outcomes stemming from unmet social, behavioral and healthcare needs. “Coupled with this economic landscape, an increase in Medi-Cal eligible residents exacerbated existing problems in the fragmented system – primarily seen through increased appointment wait times and ineffective utilization of the county’s emergency departments and hospital systems.” “Pay required to afford average rent in the county was $34 an hour and yet minimum wage remained at $9 an hour,” said Sue Crosby, whole person care program director at Contra Costa Health Services. At the time, overcrowding for low-income renters was 43% above the national average, approximately 17% of residents were living at or below the poverty level, and high housing costs required a significant portion of an individual’s income. Each WPC pilot differs in size, target population(s) and interventions based on community needs, priorities and resources.įactors in the local economic and community landscape in 2016 drove the urgency for Contra Costa Health Services in applying for the WPC grant. Up to $1.5 billion in federal funds are available over the five years of the program, matched by $1.5 billion in local funds from the pilots. The WPC pilots are testing whether local initiatives coordinating physical health, behavioral health and social services (housing supports, food assistance, other public benefits, etc.) can improve health outcomes and reduce medical costs. Recognizing that medical services only address part of a person’s overall health, the California Department of Health Care Services designed the Whole Person Care program to address the physical health, behavioral health and social needs of high-need, high-cost Medi-Cal beneficiaries.ĭHCS negotiated the program as part of its Medi-Cal 2020 Section 1115 waiver renewal with the Centers for Medicare and Medicaid Services.
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