System of Care
Opeeka's Person-Centered Intelligence Solution Enables Coordinated Care Across a System of Care
The ChallengeChildren, youth, and families who are served by multiple public programs are often challenged to navigate an uncoordinated system of care by traveling to many different agencies and knocking on many different doors. To access care, children/youth and families must tell and re-tell their stories to many different people. Once in care, multiple programs collect duplicative information, provide competing care plans, often with opposing schedules. Children, youth, and families could achieve better outcomes through a better coordinated 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, 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).
Supporting a System of CareOrganization, coordination, and support: These elements are what make a system of care meaningful for children and families who are being served by more than one program, provider, and network of service. Historically, technology has been a barrier to coordination of care. Those who were providing care had to maintain their records internally, as a means of maintaining confidentiality. But those barriers no longer make sense given the technological advancements in online information security. It is now possible to coordinate collaborative AND confidential sharing of client information in a secure and HIPAA compliant environment. Technology can now support and further enable collaboration between various health and service providers.
Person-Centered Intelligence Solution Overview
Opeeka’s P-CIS is a HIPAA compliant, multi-agency solution that allows care agencies to coordinate 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 outcomes. P-CIS converts any type of questionnaire 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.
Designed to integrate with any platform or existing electronic record, P-CIS also unifies outcome tracking across the elements of care. P-CIS unifies information through six modes: electronic record integration, direct entry, emailed invitations to complete questionnaires, Inquisitive Data Exchange (IDE) with external records, P-CIS Care Circles, and data warehouse linkages. Whether data is collected directly in P-CIS or through electronic records, P-CIS’ prudently designed multi-agency allows organizations to judiciously share very specific information about people 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 from your agency’s native electronic systems. P-CIS passes only the relevant and permissible information 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 county or state authorities will become unnecessary, freeing staff time to support information where it makes the most impact – at the point of care.
An Integrated Care Model identifies shared values, core components, and standards of practice for agencies serving children, youth, and families. P-CIS was built as a solution which supports ten guiding principles of such a model. Discussed further and with examples in Opeeka’s President’s Whitepaper, P-CIS addresses each of these topics as briefly outlined below.
P-CIS tracks each individual’s opinion and graphs perceptual differences over time.
P-CIS helps multiple staff who may be assigned to the same person to work together as a team.
P-CIS captures and tracks all family members and natural supports for a person in care. It also captures each support’s responses on assessments.
P-CIS supports multiple helpers from different agencies to work with the same information or shared records.
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.
P-CIS tracks any type and any number of affiliations (e.g., Tribe, Church, Wellness Center, Medicaid Status), preferred language, primary language, unlimited race/ethnicities, identified gender, sex, and sexual orientation. All of these options are customizable to meet local population needs.
P-CIS encourages individualized care by helping staff quickly see when care is tracking along successful trajectories, encouraging nimble adjustment to care when needed.
P-CIS tracks strengths present for each person as well as for a population. It also tracks strengths that can be built as a goal. On dashboards, staff can quickly see how strength-based the care is for a person, program, or entire agency.
P-CIS Care Compare helps staff find what has worked for people with similar circumstances in the past. This supports care circles to continue to generate ideas on what might work for this person today.
P-CIS is an outcomes management solution. It converts assessment information into trajectories of resilience and recovery for individuals, groups, programs, staff, supervisors, agencies, counties, and states. P-CIS helps identify strengths and needs for individuals and for systems alike.