Policy & Practice | October 2021

Person-Centered Care Delivered Within a Connected H/HS Ecosystem

The Current State: Siloed Service Delivery Coordinated care and a multidisci- plinary team (MDT) approach gained popularity in the health and human services (H/HS) industry during the late 1980s and early 1990s. Yet, despite the success of holistic assessments and treatment with vulnerable individuals and families, delivering H/HS services in silos remains. Burdened with policy, program, and data-sharing barriers, H/HS workers have found it easier to operate in programmatic isolation instead of facing intense barriers to work collaboratively. Well-intentioned singular service providers continue providing for singular needs the best that they can. Meanwhile individuals

again. She leaves out some details when she becomes weary. For some programs she is eligible—for others she is not. The process is lengthy and tiresome. There are different documentation require- ments for each program and she cannot keep up with all of them. Her children are wearing her out. She doesn’t have time to look for another job. Only a portion of her needs is met before frus- tration sets in and she gives up on the process, left in a state of crisis. This type of siloed, uncoordinated care has serious consequences for this mother. It applies equally to other vulnerable populations that are challenged by addiction, untreated mental health disorders, homeless- ness, reentry to society from jail or prison, youth in the juvenile justice system, and many more. Fragmented data and disconnected care networks are reasons individuals in need grow tired and give up—only to cycle back around when the next crisis hits. It is a contributing factor for frequent high-cost crisis care and long-term utilization of social programs’ over- strained budgets. Siloed data are sparse, fragmented, and unconnected among the various organizations, thereby denying providers access to

in need struggle on their own to navigate a complex system of siloed service delivery. Take, for example, a mother who loses her job due to lack of affordable child care. Her pantry cabinets are bare. She arrives at a food bank and receives a bag of groceries. Her imme- diate need is met—with a band-aid fix. Yet without working upstream to address her needs holistically, she con- tinues to the next crisis: when there is no money to pay rent and she and her children become homeless, or when other challenges arise from her situ- ation and the overwhelming stress of single parenting comes to the attention of a child welfare agency. Let’s imagine if this mother does seek services on her own. She spends hours making phone calls, scouring the internet, and seeking transportation in search of available services that are not easily located. She fills out numerous benefits applications. She goes from door to door for each of the needs she identifies are important while not rec- ognizing other needs that also threaten her family’s wellness. Since the agencies are siloed and do not have access to what she has shared elsewhere, she shares her story and data over and over

Leah Dienger , MSW, is a Senior Consultant at IBM on the Health and Human Services Public Market team.

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Policy&Practice October 2021