How Can Cross Sector Network Improve Health in Vulnerable Communities?
• Richard Gold, Stewards of Change, Silicon Valley Data Trust
• Colleen Russell, Alliance For Better Health
• Rushka Tcholakova, United Way of Greater Capital Region
• Ginger Zienlinske, Benefits Data Trust
Silicon Valley Regional Data Trust
Investing in the Future of Children, Families
and Communities
Richard GoldStewards of Change
Silicon Valley Regional Data Trust
Secure Data EnvironmentTechnology Services Platform
ChangeIntegration
Integrated Policy/Technology ArchitectureDesignDevelopment
ImplementationOperationsSustainment
Monitor &Measure
Compliance
Policy
Performance Scenario Analysis Data
Policy
SVRDT: Integrated Policy & Technology
Data Elements Use Cases Multi-Agency Agreement Universal Consent Enterprise Memorandum of Understanding
Policy and Legal Agreements
Education
SVRDT
Juvenile Probation
Juvenile Probation
Juvenile Probation
Child Welfare
Child Welfare
Child Welfare
BehavioralHealth
(3)
BehavioralHealth
(3)Behavioral
Health
Connecting Trusted Data Environments
InvolvedPerson
1
Source Links
2
Person Name
3
Person Birthdate
4
Person SSN
5
Person Drivers License
6
Person Home Address
7
Person Telephone #
8
Person E‐mail Address
9
Child Welfare
10
Behavioral Health
11
Juvenile Probation
12
Education
13
Consent
14
Consent Form Image
15
Audit Compliance
16
SVRDT User
17
User Access Control
19
Agency
18
Virtual Entities
SVRDT Canonical Data ModelOne
to One
Zero or M
any
One
or M
any
Zero or O
ne
Legend
Virtual Entities: Conceptual entities that will not instantiate as physical data stores within SVRDT
SVRDT Technical Services
Audit and Compliance
Transaction Logging
AccessPatterns
Data Security
SVRDTPlatform
Metadata (Framework)Metadata Framework(Structural)
Exchange Protocols/Standards(XML/NDR)
Semantic Consistency(Definitions)
InfoSec Protocols/Standards(AES)
Access Control
Identity Provisioning
(IDP)
Attributions&
Privileges
Resource Administration
SVRDT Data Portal
Query Manager
InvolvedPerson Linking
Transaction Logging
Identification Management
Record Location
Involved Person Matching Entity Resolution
Master PersonIndex
Message ExchangeMetadata Framework(Structural)
Exchange Protocols/Stds(XML/NDR
Semantic Consistency(Definitions)
InfoSec Protocols/Stds(
AES)
Resource Administration
SystemAdmin
User Access
DataAdmin
Consent Management
ConsentMaintenance
Rules of Use
Document Mgt
SVRDT Architecture & Services Configuration
Segment 2 – The Edge
Segment 3CDE
JPS
CW
BH
EDU
SVRDT Data Portal
Audit and Compliance
Message Exchange
Access Control
Metadata (Framework)
Resource Administration
Identification Management
Segment 3 CDE
JPS
CW
BH
EDU
Response
Request
Return
Receive
IDP
IDP IDP
Consent Management
IDP
Segment 1 – The Platform
SVRDT Platform Demonstration
Tracking Comprehensive Patient Care Services to Include Social Determinants of Health
Colleen Russell, MSN, RN-BC
Chief Health Information Officer/CIO
Alliance for Better Health
Albany, NY
Rushka Tcholakova, MSW
Senior Vice President, Community Impact
United Way of the Greater Capital Region
Albany, NY
Disclosure Statement Colleen Russell, MSN, RN-BC
Financial• Employee of Alliance for Better Health• No personal financial relevance with Unite US or United Way
Nonfinancial• Subcontractor BAA - Alliance for Better Health and Unite US• Subcontractor BAA - Alliance for Better Health and United Way
https://www.slideshare.net/paulcontino1/hfma-it-and-dsrip-technology-enabled-healthcare-paul-contino/7
What is DSRIP?
Delivery System Reform
ImprovementPlan
https://www.labormanagementinitiatives.org/new‐york‐state‐department‐of‐health‐rolls‐out‐new‐dsrip‐resources/
Working Towards Value Based
Payment
https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2015‐12‐02_opt‐out_webinar.htm
Data Sharing
• 2,000 individual providers and community‐based organizations; 213 Partners
• 190,000 Medicaid members• Covering 6 counties
• Integrated Delivery System Development• Hospital-Homecare Collaboration
• Emergency Department Triage for At Risk Populations
• Care Transition to Reduce 30-Day Readmissions
• Palliative Care Integration into Primary Care
• Integration of Behavioral Health and Primary Care
• Ambulatory Detoxification
• Strengthen the Mental, Emotional and Behavioral Health Infrastructure
• Tobacco Cessation
• Asthma Self-Management
• Patient Activation for Uninsured, Under-Insured and Low Utilizers of Health Care
Alliance for Better Health Projects
https://abhealth.us/
Integrated Delivery System
Dis- IntegrationWhy – care providers and community based organizations (CBOs) need a way to easily manage and track patient referrals
What – implement an electronic referral system, create a network of providers to send and receive referrals within our region, and expand out to other connecting regions
Unite US
Healthy Together Coordination Center
Referral Sending Options• Direct referral from service provider to service provider• Create a Coordination Center to receive and send all
referrals • Develop a Hybrid of the above
www.unitedwaygcr.org
@UnitedWay_GCR
www.facebook.com/UnitedWayGCR
2‐1‐1 Northeastern New York/United Way HELPLINE
30
@UnitedWay_GCR
WHAT IS 2‐1‐1?
1999, the Federal Communications Commission (FCC) reserved 2‐1‐1
Calls are routed by the local telephone company Databases of
community, social and government resources
Easy to remember number
Neutral, confidential resource that avoids “labels”
31
@UnitedWay_GCR
BENEFITS OF 2‐1‐1
32
Fast, free, available 24‐7‐365 & online
Comprehensive and up‐to‐date
Trained in information and referral
Aligns with social determinants of health
Data mapping & follow up
Limit results by Zip Codes
200 languages & 711 relay services
@UnitedWay_GCR
WHERE IS 2‐1‐1?
2‐1‐1 Northeast New York • Albany• Columbia• Fulton• Greene • Hamilton• Montgomery • Rensselaer• Saratoga• Schenectady• Schoharie• Warren and • Washington
www.211neny.org
@UnitedWay_GCR
WHY 2‐1‐1?
34
DSRIP
Experience & Training Footprint &
Scalability
Neutral & InnovativeState &
National Support/Best Practices
Complex Data
@UnitedWay_GCR
DEVELOP FORMAL PARTNERSHIPS
@UnitedWay_GCR
TYPES OF CALLS
36
Basic Needs, 6,074
Income Support/
Assistance1,233
Community Support
1,021Information
services 4,898
Legal/Public Safety 6,034
Mental Health 1,128
Free Tax Prep
24,375
CROSS SECTOR NETWORKS TO IMPROVE HEALTH
FOUNDED: 2005HEADQUARTERED: Philadelphia, PA
MISSION: BDT is a national not-for-profit organization committed to transforming how individuals in need access essential benefits and services.
VISION: BDT envisions a health and human services system that proactively connects individuals and families to all the supports they need to reach economic stability.
When services are well coordinated across sectors people are healthier and more economically secure; the system is more efficient and cost-effective; and our communities are stronger.
BENEFITS DATA TRUST
PERSONALIZESERVICE
DELIVERY
INTEGRATE HEALTH &
HUMANSERVICE
SUPPORTS
REDEFINE HEALTHCARE
CONNECTED, CROSS-SECTOR NETWORKS WILL…
40
THE NEED
people in America struggle to afford
food, heat and health care
Children are food insecure
of seniors in America survive on Social
Security income alone
61%Seniors that are food insecure are more likely to report heart attack
and therefore…
over
50%
41million
struggle in schoolexperience poor health
outcomeshave difficulty finding and sustaining employment
13 M
individuals are eligible butnot enrolled in SNAP9 Million
of working poorfail to access SNAP30%
41
IN ACCESS
WICEITC
eligible seniors fail to accessMedicare Part D Low Income Subsidy 2 Million
of eligible mothers fail to access WIC(Women, Infants, and Children)
45%
familiesfail to access EITC(Earned Income Tax Credit)6.45 Million
NATIONAL GAPS
HOW WE WORK: STRATEGIES TO DELIVER IMPACT
• Brokered and secured 34 data share agreements with government agencies, private sector entities, and community‐based organizations to leverage a data‐driven approach to increase access and help people meet their basic needs
• Secured $7 billion in benefits helping 500,000 households better afford food, healthcare, shelter, heat and other essential benefits
• Established Benefits Access Campaigns in 7 states (Pennsylvania, Maryland, Colorado, South Carolina, North Carolina, Connecticut and New York City)
• Enabled 200,000 Pennsylvanians to enroll in Medicaid by simply checking off a box
• Helped simplify SNAP application processes for seniors in Maryland, Colorado, Pennsylvania, and California
• Engaged in research demonstrating that SNAP reduces nursing home admittance by 23% and hospitalization rates by 14% for seniors resulting in annual healthcare savings of $2,100 per enrolled household
IMPACT DELIVERED…
?
TRACK PROGRESS IMPACT
CONNECTIDENTIFY ASSIST SUBMIT RESULTS
GUARDRAILS
PERSONALIZING SERVICE PROVISION…
PERSON-
CENTERED SYSTEM
CHANGE
INTEGRATING HEALTH & HUMAN SERVICES …
REDEFINGING HEALTHCARESenior prescription assistance
delays nursing home admissions, reduces length of stay and generates $2,300 per
capita in long-term savings
1Senior SNAP enrollment reduces
hospitalization by 14% and nursing home utilization by 23% with a per capita savings of over
$2,100 per senior enrolled
2
3 4Low-income WIC children are more likely to be immunized and receive
preventive care Increased Social Supports =
Improved Health
When you're 77, it's hard to understand some of these things.
You have been such a help today! I didn't even know they had these [benefits!] You don't
know how great that is when you're living on Social Security.”
BETTER HEALTH / LOWER COSTS
• Over 5.5 million eligible low-income seniors are not enrolled in SNAP nationwide
• Estimated healthcare savings of $2,120 per senior SNAP enrollee per year / $6,300 over 3-year recert period
• Closing the senior SNAP participation gap can produce an estimated $34 billion in nationwide healthcare savings
