Policy & Practice | October 2021

housing, employment, and health and human services. Consent and authoriza tion features that conform to applicable Health Insurance Portability and Accountability Act privacy laws and policies are implemented using HL7 FHIR data standards. Individuals with complex needs, including mental health challenges, homelessness, economic instability, and criminal justice involve ment have been among the first cohorts to engage with the overall solution of a person-centered, coordinated care service delivery model. In a short period of time, we are already seeing incredible results: increased services to more than 6,600 individuals, reduced recidivism, a 32 percent cost decrease in local Emergency Departments from high utilizers for non-emergencies, and a 7 percent drop in homelessness from 2019 to 2020. “If I could tell the number of stories of the stressors and pressures that vulnerable people feel in terms of trying to navigate all these different systems and programs—thismodel has reduced that pressurewitha nowrong door approachand is allowing for us to havemore success andhaving teams thinkmore holistically about how tomeet the needs of vulnerable individuals. We’ve been very successful ina short period of time.” —BARBIE ROBINSON, (FORMER) DIRECTOR, DEPARTMENT OF HEALTH AND HUMAN SERVICES, SONOMA COUNTY The outcomes of enabling an inte grated, coordinated care network of service providers speak for themselves in a cohort of repeat criminal offender population: “This is unbelievable.We’ve had people that were ten-time repeat offenders; they haven’t repeated once. They haven’t been pickedup once. Our recidivism isway down. All the peoplewho were enrolled in this cohort, none of themhave had jail time

since they started participating with the Interdepartmental Multidisciplinary Teamand the mental healthdiversion cohort.” —CAROLYN STAATS, INNOVATION DIVISION DIRECTOR, SONOMA COUNTY Leveraging system and data integra tion allows caseworkers, substance abuse counselors, and eligibility workers to coordinate quickly and com municate seamlessly without impact to their organization’s native IT systems. “What IBMdesigned for us, the RapidResponse system(ACCESS Sonoma), is the solution that wewere looking for. It nowenables us to have coordination between caseworkers and substance abuse counselors and eligibilityworkers, and to do it rapidly sowe can get that person back on their feet again.” —SHIRLEE ZANE, BOARD OF SUPERVISORS, DISTRICT 3, SONOMA COUNTY The Future State: Person Centered, Preventive Care Driven by Shared Data The combined impacts from SDOH, health inequities, ACEs, homeless ness, mental and physical health, and economic instability make attaining long-term health and wellness in siloed service delivery impossible. Leveraging the public health model at the fore front of the pandemic efforts, H/HS can take away best practices through the approach of identifying risk indi cators for the prevention of illness, and holistic person-centered care to address complex needs. Public health also works across disciplines, including health, education, and social services, which makes it a good model to inform an H/HS service delivery model shift. An alignment to the public health model means that H/HS can adopt at scale a common mission to reduce the impacts of risks and increase the poten tial for well-being—prevention and early intervention delivered through a compassionate, connected network of service providers fueled by a common See Person-Centered Care on page 30

the whole-person view they need to achieve improved outcomes. Gaps in care are inevitable and opportunities to intervene before problems arise are missed. Vital needs go unmet and poverty, hunger, addiction, homeless ness, and mental instability remain escalated and expensive for both the individual’s overall health and the entire H/HS ecosystem. Mindset: A Shift in Delivery Models Confronted with new faces of need and the sheer numbers flocking to assistance programs throughout the pandemic, many are questioning the blaring inefficiencies of current policies, processes, and siloed data collection. Meanwhile, conversations around prevention and early intervention strategies from a public health point of view are becoming the norm across the nation to keep individuals, families, and communities safe from illness and provide long-term physical and mental wellness. What is emerging louder than before are the effects of social deter minants of health (SDOH) and adverse childhood experiences (ACEs) on an individual’s well-being, as well as the importance of the need for fairness, equity, and just treatment of all races in current H/HS service delivery. IBM and our partners are creating innovative ways to overcome the typical policy, program, and data- sharing barriers. To achieve better outcomes, H/HS must shift to accom modate the knowledge around SDOHs, health equity, ACEs, and acknowledge their impacts on whole-person well being. Health and human services must address health equity and aim toward interventions that are fair and equitable for all. And finally, H/HS must explore options to securely integrate data across organizations, turning quality data into insights that initiate prevention and early interven tion actions that drive reduced costs and life-changing outcomes. A great example of success is IBM’s work with Sonoma County to create the ACCESS Sonoma initiative and system (https://sonomacounty.ca.gov/CAO/ Projects/ACCESS-Sonoma/) . Underlying technology enables the integration of source system data that includes

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October 2021 Policy&Practice