How P-CIS Enables Coordinated Care For Multi-system Served Children, Youth And Families: A Focus On California’s AB 2083 Requirements

How P-CIS Enables Coordinated Care For Multi-system Served Children, Youth And Families: A Focus On California’s AB 2083 Requirements


This begins a conversation about how to remove technology barriers from the system of care in order to support collaboration and coordination of care for multi-system served children/youth and families.

What are The Challenges in the System of Care?

Children, youth, and families who are served by multiple public programs are often challenged to navigate an uncoordinated system of care by knocking on many “wrong doors.” To access care, children/youth and families are being re-traumatized by telling and re-telling their stories to multiple care agencies. Once in care, multiple programs collect duplicative information, provide competing instruction and implement opposing schedules. Children, youth, and families could achieve better outcomes through a more coordinated system of care. (Stroul & Blau, 2010).

Child & Family Teaming

What is the System of Care?

“A system of care is a spectrum of effective, community-based services and supports for children and youth with or at risk for mental health or other challenges and their families, that is organized into a coordinated network with a supportive infrastructure, builds meaningful partnerships with families and youth, and addresses their cultural and linguistic needs, in order to help them to function better at home, in school, in the community, and throughout life.” (Stroul and Blau 2010, p61).

What is California’s Assembly Bill 2083?

In support of a unified System of Care, California’s Assembly Bill 2083 (AB 2083, Chapter 815, Statutes of 2018) calls for a memorandum of understanding (MOU) between local partners including child welfare, regional center, county office of education, probation and county behavioral health. A Child and Youth System of Care Technical Assistance State Team was assembled to promote collaboration between communities across systems to meet needs of children, youth and families; to support timely access to trauma-informed services for children and youth; and to resolve technical assistance request by counties and partner agencies to meet the needs of children and youth.

How can P-CIS help for AB 2083?

Opeeka’s Person-Centered Intelligence Solution (P-CIS, /pieces/) was designed to be a system that could remove the technological barriers that often inhibited collaboration and coordination in the system of care. Opeeka has assembled a team of thought leaders, policy advisors, data scientists and computer engineers. The team designed P-CIS to put the person at the center of a system of care.

System of Care - Care Circle

How can Person-Centered Intelligence Solution (P-CIS) help coordinate care?

Opeeka’s P-CIS is a HIPAA compliant, multi-tenant architecture solution that would allow care agencies to track outcomes over time, from an initial screen to post-care satisfaction surveys. Assessments are at the heart of every care system, helping to identify eligibility, level of care, rate of reimbursement, cultural preferences, level of need, areas of strength, functioning, past experiences, diagnosis, progress, satisfaction and final disposition. P-CIS converts any type of assessment information into meaningful information at the point of care, mapping responses onto story maps and trajectories of resilience and recovery. P-CIS connects data directly to analysis engines, so that information gathered is immediately funneled into outcomes evaluation – so that care can be adjusted while people are still in care. See Opeeka’s President’s Whitepaper for more information about specific functionalities of P-CIS.

Does P-CIS integrate with my electronic record?

Designed to integrate with any platform of existing electronic record, P-CIS also unifies outcome tracking across the system of care. Prudently designed multi-tenancy allows agencies to judiciously share very specific information about clients who are co-served, encouraging teaming, and coordinating efforts for multi-system and cross-county care. The inter-operability with electronic records means that staff will not need to find and log into yet another system of siloed information as P-CIS can launch effortlessly from native electronic systems. P-CIS passes only the relevant and permissible information on assessment scores back to the electronic system of record, allowing audits to continue from within existing systems of authority without change. However, because P-CIS supports HIPAA compliant multi-tenancy, this means that error-prone and burdensome secure file transfer to state authorities will become unnecessary, freeing staff time up to support information systems where they make the most impact – at the point of care.

Mental Health Outcomes Software

What are the Principles of California’s Integrated Core Practice Model?

This California Integrated Core Practice Model (ICPM) identifies shared values, core components, and standards of practice for agencies serving children, youth, and families. P-CIS was built as solution which supports the ten guiding principles of the ICPM. Discussed further and with examples in Opeeka’s President’s Whitepaper, P-CIS addresses each of these topics as briefly outlined below.

ICPM Guiding Principles Operationalized in P-CIS

1. Family voice and choice. P-CIS tracks each individuals opinion and graphs perceptual differences over time.

2. Team-based. P-CIS helps multiple staff from who are assigned for the same person to work together as a team.

3. Natural supports. P-CIS captures and tracks all family members and natural supports for a person. It also captures each support’s responses on assessments.

4. Collaboration and integration. P-CIS support multiple helpers from different agencies to work in the same or shared person records.

5. Community-based. P-CIS tracks person participation in residential and community-based settings. It automates algorithms which instantly produce recommendations for step-down care so that a person in residential care can return to lower-intensity community-based care more quickly.

6. Culturally respectful. P-CIS tracks any type and any number of affiliations, preferred language, primary language, unlimited race/ethnicities, identified gender, sex, and sexual orientation. All of these options are customizable to meet local population needs.

7. Individualized. P-CIS encourages individualized care by helping staff quickly see when care is tracking along successful trajectories, encouraging nimble adjustment to care when needed.

8. Strengths-based. P-CIS tracks the number of strengths identified to build and strengths present for each person as well as for a population. On dashboards, staff can quickly see how strength-based that the care is for a person, program, or entire agency.

9. Persistence. P-CIS Care Compare helps staff find what has worked for similar people with similar circumstances in the past. This allows care circles to continue to generate ideas on what might work for this person today.

10. Outcomes-based. P-CIS is an outcomes management solution. It converts assessment information into trajectories of resilience and recovery for individuals, groups, programs, staff, supervisors and agencies. P-CIS helps identify strengths and needs for individuals and for systems alike.

How will improved outcomes tracking help?

“The drive for improved outcomes and more efficient services for children, youth, and families receiving care from government supported systems requires improved tracking and data-informed decision-making at all levels — policy, program, and practice” (Kent & Lightbourne, n.d.).

What are the processes for screening, assessment, and entry to care?

A child or youth’s access to the systems of care can be difficult due to restricted pathways (e.g., families must enter system through child welfare agency to access school-based mental health related services) and limiting criteria for entry (e.g., families must have specific set of circumstances or diagnoses), with families turned away from service because they tried to access certain services through the ‘wrong door’ (Miller, Blau, Christopher, & Jordan, 2012). When a child/youth presents for care, an agency might not know about or have access to the same screens or assessments already performed by another agency in the system of care. The child/youth and family must complete the same screens and assessments multiple times at different agencies to access a necessary part of care.

What if an agency changes their screening, assessing and determination of care?

The process for screening, assessing and determination of care are specific to an agency and local population. These processes also adapt as policies and population needs adjust over time. A system which facilitates screening, assessment and entry to care must be flexible to accommodate a wide variety of processes and adaptive to adjust over time. P-CIS manages any type of screen or assessment, applying level of care and rate determination algorithms to produce recommendations immediately upon completion. All of this functionality is flexibly customizable by organization administrators. When screening or assessment processes change, local agencies can directly adjust settings in P-CIS, and P-CIS implements the change in process across care – instantly.

What is a Care Circle?

In addition, P-CIS supports sharing of that information a Care Circle. When two or more agencies agree to collaborate to serve children/youth for certain types of care, each agency can designate exactly which programs/practices to share, which contingent screens/assessments to share, and which contingent questions to share for which individuals under which circumstances (e.g., release of information was obtained, a signed waiver was collected, informed consent was gathered.) In this way, when a child/youth presents for care, an agency that is part of a Care Circle in P-CIS can search for that person and access any legally shared screens and assessments for that child/youth — for just the questions and responses which were not redacted. If the screen or assessment was recent, then the child/youth and family do not need to undergo another of the same type of screen or assessment. Any additional screens/assessments can be shared back. Notes related to that screen or assessment will alert the care partner about complementary care, and the staff can work together to coordinate plans. Now, there is no ‘wrong door,’ because all doors lead to the person-centered care which is centralized in P-CIS.

No Wrong Door

Continue to Next Blog?

This is Part 1 of the blog. Continue on to Part 2 here or download the entire concept paper here.


Kent, J., & Lightbourne, W. (n.d.). The California Integrated Core Practice Model for Children, Youth, And Families. Department of Health Care Services & California Department of Social Services.

Miller, B. D., Blau, G. M., Christopher, O. T., & Jordan, P. E. (2012). Sustaining and expanding systems of care to provide mental health services for children, youth and families across America. American Journal of Community Psychology, 49(3–4), 566–579.

Stroul, B. a, & Blau, G. M. (2010). Defining the system of care concept and philosophy: to update or not to update? Evaluation and Program Planning, 33(1), 59–62.