Transformational Integrated Care Solutions

Transformational Integrated Care Solutions
Solutions must be built into the work of every system to ensure sustainability, which supports transformational care.

Solutions for Success Must Be Sustainable

Very rarely are interventions successful using a ‘One and Done’ approach. Instead, the work around development of treatment plans and teams must be embedded within all levels of local systems of care to create a systemic shift in sustainability. Solutions must be built into the work of every system to ensure sustainability, which supports transformational care.

Every human is multi-dimensional, just like the world in which they live. Those we serve are not a single story, instead their lives are full of many parts which create an intricate tapestry of stories. However, too often we are not focused on whole-person and there is so much we are missing, leading to misunderstanding, mislabeling and even mistreatment. Instead, systems must collaborate with other systems while providing comprehensive successful care, beyond just meeting basic deliverables towards building protective factors for life-long success.

Effective solutions exist now to effectively support collaborative systems work. Opeeka’s Person-Centered Intelligence Solution or P-CIS (appropriately called pieces) effectively supports the values and principles of systems of care, by increasing systemic collaborations while monitoring care in ‘real-time.’ P-CIS is a ‘transformational care collaboration’ system, allowing for shared data, via multiple electronic health recorders (EHRs), to be analyzed in ‘real-time’ to specifically supporting the work of wraparound, child/family teams, and the use of TCOM Tools was to unify information gathered.

Operationalizing Transformational Care-Collaboration

Operationalizing Transformational Care-Collaboration

We must also prevent the ‘needs’ of those we serve to not define that individual, where they become a ‘single story. Instead, care must be taken ensuring that individuals are seen within the context of their life-domains: home, school/work and community. Getting to know and understand a person while capturing both their needs and strengths is what Transformational Collaborative Outcomes Management or TCOM and the associated tools (CANS, ANSA, FAST) have been developed to accomplish.

What is ‘Transformational Care-Collaboration? Transformational Care-Collaboration’ can be defined as:

The collaborative process of engaging those being served, developing goals of life through conversations and relationship building. These goals are to assist with getting them back on track to effectively manage life challenges. Transformational Care-Collaboration serves to actively coordinate the care an individual is receiving. This ‘team’ approach serves to support the individual (person-centered care) and the individual within each life domain (whole person).

Transformational Care-Collaboration is completely aligned with Transformational Collaborative Outcomes Management (TCOM), specifically TCOM’s Core Principles & Guiding Values (Praed Foundation, 2022):


  • Human serving systems and enterprises have a primary mandate of facilitating and supporting personal change (transformation)
  • Human serving systems and enterprises are inherently complex because of the multiplicity of human involvement. Multiplicity can only be managed through integration. Integration among people is best managed through collaborative processes.
  • All partners in human serving systems and enterprises have a primary responsibility of collecting, managing, and using accurate, relevant, and respectful information about the people served


  • All assessments and interventions should be culturally responsive and respectful
  • People should have voice and choice with regard to all assessments and interventions
  • All interventions should be personalized, respectful and have demonstrable value to the people they serve.
  • Collaborative processes should be used for all major decisions at all levels of the system
  • Consensus is the primary outcome of collaborative processes
  • Information about the people served and their personal change should always inform decision-making at all levels of the system
Transformational Integrated Care Solutions

Transformational Care-Collaboration: An Integrated Care Solution

Many care-coordinators are struggling to keep up with challenges which include impact of the pandemic, complexities of needs and deadlines connected to paperwork. So, to offer a new approach to care-planning may be difficult to comprehend and accomplish. However, ‘Transformational Care Collaboration’ it is not a ‘new’ treatment planning process, rather it is an organizational shift to the work itself. Like the TCOM Tools, which organization information gather, transformational care collaboration supports whole-person care, empowering those within care to take the lead in their health & well-being.

Most care planning processes begin with identified needs, especially ensuring safety, along with developing strategies or steps towards outcomes and goal setting. This is a very simplified version of care planning, but useful for discussion purposes. However, much too often the focus remains only on symptom(s) reduction and surface needs (school refusal=get youth to attend regularly). This is the ‘single-story’ phenomenon which was discussed earlier.

Instead, it is just as important to know about the ‘why’ as well as the ‘what’ as it relates to their refusing to go to school, which aligns with a more integrated care solution for transformation. Often the missing component throughout care are connections to others. Using the school refusal example, let’s say the reason for not attending school was to avoid feeling anxious. The question then becomes focused on treating the anxiety and evaluation of ‘connections’, including people and supports/services.  This ‘whole-person’ care approach can prevent only focusing on the ‘single story’ and instead capturing underlying needs, while building connections and strengths.