Lessons Learned Supporting Integrated Care Solutions
Looking back at the 2-decades spent actively involved in a statewide children’s system of care, I have learned there is so much more we need to do structurally and systemically to improve better outcomes for children, youth, emerging adults, & families. The essence of communimetrics (CANS Tools) has been used to support person-reported outcomes measure for decades. Communimetrics is based in the science for measuring communication and action in human services/social services environments. Increased positive outcomes can result when CANS is strongly embedded in Wraparound and utilized within child/family team to support individualized care-planning.
The ‘team’ approach must not be nominal but instead active and knowledgeable of its purpose, person-centered care planning. A care-team or ‘care-circle’ has the charter of fulfilling specific tasks, moving those in care closer towards real ‘whole-person care.’ However, often absent in team membership are informal or natural supports which have existed prior to treatment and support individual in care as well as larger family system. Some examples of these members include extended family/friends, neighbors, spiritual leaders, teachers, coaches.
Whole Is Greater Than Sum Of Its Parts-Coordinated Care Planning
Coordinated Care Provider is a term that many think only applies to physical health. However, the actual definition of coordinated care can vary between the type services being provided and are sometimes called case management, collaborative care, shared care, team coordination, and multidisciplinary care.
An effective method of care coordination model in systems of care is the ‘care-management’ approach. The care-management organization (CMO) coordinates comprehensive care-planning, setting up pre-determined face-to-face team (or virtual-hybrid) meetings in development of an individualized comprehensive care plan with those being served (individuals/families). The execution of these plans takes place in-between meetings, are monitored for progress and revised if needed when progress is not seen. Coordinated care plans can include all types of health care providers (physical/mental health care, addiction/recovery services, dental/eye care providers), educational professionals, spiritual/religious supports and others all working in collaboration.
When these plans are well-coordinated the results are positive outcomes. The challenge is coordinating care providers are relegated to formal health services and often do not extend to natural and/or informal community supports. An additional and more substantive challenge revolves around siloed information and lack of ‘real-time’ data sharing to support effective coordinated care planning. Sadly, many individuals receive only fragmented care, without these supports which are often needed to ensure successful integrated care.
So why does integrated care remain in the realm of possibility and not as a reality? This is especially frustrating when research has shown its effectiveness, especially when the philosophy of care encompasses four components: 1) whole person framework, 2) personalized or individualized care, 3) person/patient centeredness, and 4) a focus on health/wellness.
Person-Centered Intelligence Solutions Meeting 21st Century Needs
So, it seems to me that we must move forward with solutions, as we are 20 years into the 21st Century. Many nay-sayers of innovative ways of moving forward might voice concerns around the tactical means for successful implementation, along with perceived high costs attached. Well, as someone who has actively participated in the successful implementation of a state-wide system of care for children/youth & families, seeing first-hand the gaps and limitations of antiquated technologies the cost of inaction is inexcusable. There is now a ‘real’ solution available, Opeeka has developed an innovative technology called Person-Centered Intelligence Solutions (P-CIS), aptly pronounced pieces.
Opeeka’s mission is to promote well-being for all. Enabling whole-person care, bringing care full circle, considering individuals as complete humans, identifying care that works for similar types of people, and assisting communication between people and care providers.
Person-Centered Intelligence Solution P-CIS helps to support critical data sharing, which is essential for healthcare providers to achieve integrated care. The sharing of information, while maintaining HIPPA & 42-CFR compliance, reduces costs while enhancing value-based healthcare. It is also known as value-based care, which is a payment model rewarding healthcare providers for providing quality care to those individuals in their care. Opeeka’ P-CIS takes analytics a step further with its enhanced success-focused artificial intelligence (SF-AI) eliminating the 80/20 rule. Research has shown that providers often spend 80% of their effort/resources serving 20% of total population.
P-CIS incorporates success-focused care rather than a risk-assessment approach, tracking success-highlighting the trajectories of recovery and resilience for people with complex care needs. Success-focused care combines person-centered and whole person care to develop a person’s ‘story map’, while identifying patterns of success for similar populations of people using Success-Focused Artificial Intelligence (SF-AI). All of this is done utilizing ‘real-time’ data in progress tracking. P-CIS facilitates tracking of progress toward goals by evaluating how needs and resilience change over time. Results are people experience increased ‘voice & choice’ along with positive outcomes, especially when are seeing progress throughout time in care in ‘real-time.’ In addition to people in care positive outcome, staff who serve experience increased satisfaction knowing they played an important role, strengthening impact in their job performance & work-force well-being.
Communimetrics & TCOM-A Worldwide Knowledge Base
Dr. John Lyons along with the larger worldwide TCOM Collaborative have worked towards health equity, especially for those who have long been marginalized in society. Transformational Collaborative Outcomes Management or TCOM is an approach grounded in a philosophy of a single shared vision–helping people achieve their health and wellness goals as they navigate healthcare, child welfare, justice, behavioral health, education, and other complex systems. TCOM and the Communimetric tools are currently being used around the world, including throughout the United States, Canada, Europe, Asia, and Russia.
The TCOM Collaborative is highlighted yearly at the annual TCOM Conference, which have taken place over the past 17 years. These events are like no other in that accomplished are not just on display, but a full range of information, lessons learned as well sharing ideas and resources which has developed into a worldwide mass collaboration among various human service systems. Most typical conference are only focusing in on capturing the successes of a discipline. I have attended, and presented, over the past 15 years and can honestly tell you that I have met folks from child welfare, academia, mental health, community health centers, parents/former youth who have received services and many others from around the globe. Many of whom I have known since first attending and become dear friends with, who I can reach-out for questions, to gain perspective or just say, ‘Hello.’
Let’s see if what we have so far. We have accumulated knowledge and amassed huge amounts of research connected with the human-service field. In more recent years we have realized that health service delivery systems have not been entirely fair and equitable. In addition, we know more about adverse childhood experiences and how left untreated can negatively impact both our physical and mental health later in life. Research supports preventive health and well-being measures, especially whole-person focused care. There are also evidence-based practices (EBP) which support positive outcomes for specific individuals, groups, and experiences.
Putting the P-CIS (Pieces) Together-Achieving Health Equity!
Person-Centered Intelligence Solution is an innovative and secure cloud-based technology which allows the integration of electronic records to unite information successfully and meaningfully in one place. This results in ‘real-time’ data sharing and collection, or simple the information follows those in care. As a result of safely sharing information between agencies it prevents those from having to constantly repeat their story over again and again.
P-CIS actively supports joint care planning (HIPAA & 42CFR compliant) ensuring aligned care planning among various systems. As an administrator, supervisor, direct-line staff it eases the burden of data collection, so not to take away from the actual work being done in effectively treating those in care. So much time is spent in redundancies connected with data reporting to authorities. Technology should be used to solidly execute care-plans, while tracking progress back to point of care and to the family in real-time. Thereby time can be better spent capturing child/youth, family, and support voices by incorporating technology and maintaining fidelity measures connected with evidence-based practices, especially Wraparound and Child/Family Team (CFT).
In looking back on my systems of care (SOC) journey there were so many gaps needing to be filled in to increase overall effectiveness. It was only after serving as a Regional Director for the Contracted Systems Administrator (CSA), Clinical Director/Director of Operations of a county-based Care Management Organization (CMO) and Senior Training/Consultation Specialist as part of a team at a Behavioral Research Training Institute that I come to the following conclusion. Using a technology like Person-Centered Intelligence Solution (P-CIS) can support the original goal of systems of care and those updates to SOC concept and philosophy as outlined by Beth Stroul, Gary Blau and Robert Friedman.
The time has come to move forward and make the shift from systems of care towards ‘systems that care.’
Join Us for a ‘TCOM Town Hall with Dr. John Lyons: Using Technology In Supporting Our Work’ Where we will look ahead towards the future and how we can move forward improving the outcomes managing the data.