Policy & Practice | Spring 2023

Connecting systems ultimately provides individuals with a better chance of living a full life. Technology may not solve homelessness, but it is instrumental in reducing it.

which empowers care workers, pro viders, families, and caregivers to collaborate and support the needs of individuals. It connects existing systems of health (there’s that phrase again!) around each person’s unique health care needs, with full mobile support and human-centered features. IHI Aim 1: Enhance the Individual Whole-Person Care Experience Jessica’s incarceration triggered the Sonoma County safety net collabora tive. With their support, she joined a mental health diversion program, enrolled in homeless services, and accessed supplemental security income. With the right support in place, Jessica stabilized her mental health symptoms and achieved sobriety. This happened through interde partmental, multidisciplinary teams coordinating Jessica’s care and setting case plan goals to address her specific needs. Her story isn’t unique. Since 2017, Sonoma County has moved more than 700 individuals off the streets. They’ve sheltered 512 unique individuals and enrolled 578 unique individuals in case management. Sonoma County Human Services has 50 offices serving 145,000 out of roughly 500,000 county residents. In the last six years, they’ve engaged with more than 8,000 individuals; achieved a 35 percent permanent housing placement rate—compared to the national average of 8 percent; and celebrated a 7 percent decrease in Sonoma County’s population that was unhoused. Jessica is one of them. IHI Aim 3: Reduce Costs Sonoma found that the top 1 percent of their service utilizers accounted for $27,000 per person annually in state and county services. 4 They started an initiative supporting people who were unhoused and seeking treatment for non-emergency conditions at a local emergency department (ED). As a result, the ED recorded a 32 percent decrease in hospital costs because of IHI Aim 2: Improve Population Health

Systems of Health And Jessica? In 2022, she graduated from the mental health diversion court and her felony charges were dismissed. Jessica has permanent housing, is com mitted to remaining in mental health services, and has the resources needed to make sure she doesn’t fall through the cracks in the system. With a coordinated and holistic approach, government agencies can move caseworkers, frontline workers, and the people they serve toward longer-term solutions. Connecting systems ultimately provides indi viduals with a better chance of living a full life. Technology may not solve homelessness, but it is instrumental in reducing it. Read more about Sonoma County’s success at merative.com/SPMclients. Reference Notes 1. CMS.gov. (2022, March 28). CMS Office of the Actuary releases 2021n dash2030 projections of national health expenditures. https://www.cms.gov/ newsroom/press-releases/cms-office actuary-releases-2021-2030-projections national-health-expenditures 2. The Commonwealth Fund. (2021, August 2). Mirror, mirror 2021: Reflecting poorly. Health care in the U.S compared to other high-income countries. https://www.commonwealthfund.org/ publications/fund-reports/2021/aug/ mirror-mirror-2021-reflecting-poorly 3. Nundy, S., Cooper, L. A., & Mate, K. S. (2022, January 21). The quintuple aim for health care improvement: A new imperative to advance health equity. JAMA Network. https://doi.org/10.1001/ jama.2021.25181 4. Augustine, E., & White, E. (2020, July 7). High utilizers of multiple systems in Sonoma county. California Policy Lab. https://www.capolicylab.org/high-utilizers of-multiple-systems-in-sonoma-county David Gruen , MD, MBA, is the Chief Medical Officer at Merative.

fewer admissions from patients who were unhoused.

IHI Aim 4: Improve Provider and CareTeams’ Well-Being So how is Merative TM Integrated Care working internally? The 52-person staff report that they love using the system and find a lot of benefit from it (When was the last time you heard staff excited about new technology?). For one, they wanted to focus on the clients with the highest needs—those that bounced between county services but never progressed. Now, for the first time, caseworkers and service providers can collect, share, and keep up with clients in real time—directly from mobile devices and across agencies. IHI Aim 5: Pursuit of Health Equity Sonoma County’s network removed barriers Jessica couldn’t overcome on her own. She was able to progress because of: n Behavioral health treatment n Employment and income security n Suitable and stable housing n Food security n Physical health services n Substance use (treatment or harm reduction) These wraparound services are paramount to Jessica’s success. They’re tangible ways to tackle equity. And because people are fully integrated into a system of health, they no longer need to visit a county office on certain days between set hours for services. Mobile technology enables caseworkers to visit residents who are unhoused in tent cities, shelters, and jails. All of which improve care coordi nation and lower costs.

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