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Montgomery County, Maryland | Department of Health and Human ServicesOctober 7, 2013

Integration and Interoperability in a Health and Human

Services Enterprise

WHO WE ARE:

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Information about our County

3Department of Health and Human Services

Almost 1 Million Residents__________

31% Foreign Born

50.6% Ethnic Minority

17% Growth in our senior population

over the next 2years

49,344 out of 148,779 children in the public school system receive

FARMS

6 Zip Codes of Extreme Need —

Poverty on the Rise

Served 120,000 Households in Fiscal Year 2012. One-third used more than two

services from Department

A Staff of 1,600 with over 80 Programs

Caseloads GrowingTCA: 43.4%SNAP: 166%MA: 68.7%

Serving almost 36,000 uninsured

adults, children and pregnant women

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How is the Department Organized?

In 1994, Four Departments Became One

Entity

OBJECTIVE: Integrated, Coordinated

and Comprehensi

ve Service Delivery

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Montgomery County Department and Health and Human Services

Continuum of Programs Aging and Disability

Services Behavioral Health and

Crisis Services Children, Youth and

Family Services

Public Health Services

Special Needs Housing Office of Community

Affairs

John J. Kenney Chief

Raymond Crowel Chief

Kate Garvey Chief and Social Services

Officer

Ulder J. Tillman Chief and Health Officer

Nadim Khan Chief

Betty Lam Chief

Information and Assessment Services

Home and Community Support Services

Community Support Network | Disability Services

Home Care Adult Protective Services |

Case Management Services Nutrition Program Assisted Living and Skilled

Nursing Facilities Assisted Living Services Ombudsman Program Boards and Commissions

.. Commission on Aging

.. Commission on People with Disabilities

.. Adult Public Guardianship Review Board

Mental Health Services Adults and Seniors Children and Adolescents Multicultural Mental Health

Services Core Service Agency Substance Abuse | Addiction

Services Crisis Stabilization Juvenile Justice Partner Abuse Victim Abuse Boards and commissions

.. Alcohol and Other Drug Abuse Advisory Committee

.. Mental Health Advisory Committee

Linkages to Learning Child Welfare Child and Adolescent Services Early Childhood Services Gang Prevention Initiative Income Supports and Child Care

Subsidy Liaison Work with MCPS Boards and Commissions

.. Commission on Children and Youth

.. Commission on Child Care

.. Commission on Juvenile Justice

.. Citizens Review Panel

Community Health Services Communicable Disease| Bio-

Terrorism Cancer and Tobacco Initiatives Licensure and Regulatory

Services Assisted Living Facilities

Certification School Health Montgomery Cares Health Promotion Health Partnerships and

Planning Long Term Care Medical

Assistance and Outreach Special Projects Boards and Commissions

.. Commission on Health

.. Montgomery Cares Advisory Board

Housing Stabilization | Emergency Services to Prevent Homelessness Economic Supports Emergency Assistance Grants Welfare Avoidance Grants 60-Month Intervention Resource Supports Preventive Crisis Intervention

with Case Management Rental and Home Energy Assistance Program RAP - Shallow Rental Subsidy

Program SHRAP – Deep Rental Subsidy

Program Handicapped Rental Assistance

Program Home Energy Assistance

Program Homeless Continuum of Care Coordination (Supported through non-profit partners) Single Adult Shelters w|case

management Motel Placements and

Overflow Shelters Transitional Programs Permanent Supportive Housing

Programs

Community Action Agency Community Outreach Disparity Reduction Diversity Initiatives and the

three Minority Health Initiatives

LEP Compliance

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How is DHHS Organized?

One Director

Centralized Administrat

ive Functions

Moving towards single client

record supported by an

interoperable databaseUniform intake

form to identify all service needs

Designated entire HHS entity as

HIPAA covered – including social

service and income support

programs

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No Wrong Door in the Future.

Seamless customer experience integrated in all 50 sites (27 program sites and 23 clinic sites)

Key to the experience will be: Access to all DHHS Programs Shared information and data Customer telling their story once

TECHNOLOGY MODERNIZATION

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An Aspect of Interoperability.

Integrated Case Practices Integrated Business

Process Enterprise-wide Client

View Improved Outcomes Analytics and Individual

Client Focus and Population Health Focus

Technology Modernization

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The Process and Technology Modernization (PTM) Program lays the foundation for changing DHHS service delivery over the next few years.

Changes in service delivery best practice

Changes required by the Affordable Care Act (ACA) implementation

Difficulty/cost in maintaining many one-off applications supporting programs

Inefficiencies from using multiple state systems

Improve client outcomes Reduce overall costs of

treatment Establish single platform for

most service delivery Prepare for ACA-mandated

changes Simplify ongoing application

maintenance Realize vision of integrated

DHHS

Drivers Goals

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Service Delivery Today.

Service IntegrationTreatm

entTreatm

entTreatm

entTreatm

entTreatm

entAssessm

entAssessm

entAssessm

entAssessm

entAssessm

entEligibili

tyEligibili

tyEligibili

tyEligibili

tyEligibili

tyIntake Intake Intake Intake IntakeAging

& Disabili

ty

Behavioral

Health

Children Youth

& Familie

s

Public Health

Special Needs Housin

g

The PTM Program will help HHS transform from disjointed, inefficient, program-based silos … Clients have to

“shop” for services

No consolidated view of client engagement with HHS

Integrated service delivery for only the hardest-to-serve clients

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Service Delivery Tomorrow.

Treatment

Assessment

Eligibility

Intake

Aging &

Disability

Behavioral

Health

Children Youth

& Familie

s

Public Health

Special Needs Housin

g

… to a more integrated service delivery model that treats clients holistically and cost-effectively. No Wrong Door

for residents needing services

Consolidated view of client engagement across most programs

Integrated service delivery where appropriateClien

t

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Because we want to provide

seamless, consistent services to our clients

across HHS, we seek to define and implement common

processing, approaches

and methods

throughout HHS

Because we want to

maintain and upgrade our systems over time, we will leverage the

existing functionality of the software as fully as possible and minimize customization

Because we want to treat clients in

holistic, integrated

manner, we will share

information about our clients

and their treatment within

HHS, unless prohibited by law

We will never let the

perfect be the enemy of

the good

We adopted four guiding principles to serve as touchstones

as we move forward.

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The PTM Program includes 7 Interrelated Projects.

1. Enterprise Integrated Case Management (EICM)2. Enterprise Content Management System (ECMS)3. Electronic Health Record (EHR)

4. US HHS Interoperability Grant5. Organizational Change Management (OCM)6. Project Management Office (PMO)7. Quality Assurance (QA)

IT Implementations

Supporting Projects

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C

B

A Application HUB (share application; eliminate dual entry)

Dependencies -

Integrations/Conversions (single view of client)Dependencies – CIS/SAIL integration – Person Query (existing), Person Registration, Case Query (existing) Case Registration (CARES, OHEP), ECMSData conversion - CIS, CARES, OHEP

C Check-in / Clearance ApplicationRegistratio

n

LotC Com

mon/

Core Functions

Eligibility Determinati

on

WPA

RAPADS Risk AssessmentSubsume

dD

Target Phase 3 First Half

Appointment

Scheduling

Service Area Customization

Service Area / Local

Program

Specific

Check-in / Clearance ApplicationRegistratio

nAppointme

nt Scheduling

Eligibility Determinati

on

Case Assignme

nt

Program Referral

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C

B

A Application HUB (Add new sources)

Integrations/Conversions (Add new sources)

CRecord

Assessment Results

Service Referrals (Manual)

Provider Enrollment

LotC Com

mon/Co

re Functions

Service Plan

Service Strategy

D

Target Phase 3 Second Half

Case Dispensati

on

Provider / Serice Match

Service Area / Local

Program

Specific

WPA

RAPADS Risk Assessment

Service Area Customization

Reporting/Analytics

MCDHHS Master Clients

Resources Services

Client Demographics

Active Enrollments

Provider/Service History

eICM

Conversion and Batch Integration Strategy

Iterative Conversion Process

State/FederalSystems of Record

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Integration with Systems of Record

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NIEM – Based Application Hub

eICM

Case Management Modules

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CASE MANAGEMENTAutomated in eICM

SERVICE TRANSACTIONCurrent process

Using System of RecordMANAGE CASE ACTIVITY

MANAGE CLIENT PARTICIPATION

MONITOR CLIENTPROGRESS

MANAGE SERVICEBUDGET

DELIVER UNITS OFSERVICE

VERIFY CLIENTPARTICIPATION

REPORT SERVICEMILESTONES

INVOICE FOR SERVICESRENDERED

MONITOR PROVIDERFULFILLMENT

CM/ST Interactions21

eICM Service Referral

State System of

Record

Service Transaction

Details

Case ManagerService Transaction

Details

ProviderBatch

Process

CONFIDENTIALITY AND PRIVACY

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Policy and Practice Business Process Need to Know Role-Based Access Balance between

Interoperability/Data-sharing and Guarding against Breaches

An Aspect of Interoperability.Sharing of Information

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Confidentiality:

Sharing Information within

our Multi-

Service Agency

Definition of treatment in the regulations include “related services”

In context of our department, related services include income support and social services Addressing a client’s basic food or shelter needs

greatly impacts the effectiveness of health care Both the intent of the law and

language in the rulemaking process supports this broad interpretation

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Infrastructure to Promote

Service Integration and Ensure

Privacy Compliance

Revised Notice of Privacy Practices

Common Authorization

Form

Department-Wide Policy

(Example: Safeguarding Policy)Role-based

Access; Access based on a job

related purpose

Minimum Necessary

Training

Resources

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Why Integrate Data?

Over 30% of our clients use multiple servicesClients often have to tell their story multiple times and data has to be entered multiple times. Increases the risk of errors in the re-telling and re-enteringWithout a master client index, it is hard to tell what services a client is getting across our enterprise and often services are duplicated and there is waste and inefficiencyMakes re-use of data impossible and it makes it more difficult for clients to access multiple services across the enterprise

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What is our Approach? We have a HIPAA Policy and Risk Manager leading

an office of 2.5 positions Continuously updating and staying on top of the

federal and state policy environment Continuously training and working to align policy Our Process and Technology Modernization efforts

which include the following – ECMS, eICMS, EHR, MCI, Legacy Systems and MCDHHS Portal will have policy, business process and practice alignment for HIPAA, 42CFR and other privacy statutes and regulations

RETURN ON (TAXPAYER) INVESTMENT/SOCIAL RETURN ON INVESTMENT

Work led by JHU Public Health Informatics School and Accenture Slides attributed to Dr. Harold Lehmann

Background Application of cost-effectiveness analysis

to human services Washington State Institute for Public Policy Evidence vs local data

Decision oriented Klazinga, et al. Int Soc Qual Heal Care 2001

Social return on investment Cresswell; sroinetwork.org

vatic

anus

Outcome Measures

Case

Architectural Model

CostsBenefits

To Be As Is

RO(T)I Results

Standard Practice

With Interoperability

Costs Incurre

d

Costs avoide

d

Costs Incurre

d

Costs avoide

d

Net

Test case 1Homeless

Test case 2Youth in

Transition

Monetizing Impact:Net Benefits by Stakeholder

Public DefenderState DOC

District CourtCity Attorney

County AttorneyProbation (Community Corrections)

Arrest (Sheriff)Jail (Sheriff)

0%10%

20%30%

40%50%

60%70%

80%90%

100%

Criminal Justice Cost BreakdownLocalStateFederalOther

     Dakota County   Other Counties   State of MN   Federal   Other   TOTAL 

 Cost  Cost 1 Cost 2… Total Cost of RAP

 

 Benefit (Criminal 

Justice Cost Avoidance) 

Jail Arrest Probation … Total Cost Avoidance Attributable RAP 

   Benefit 

(Community Impacts) 

Benefits Not Quantified Tax Revenue Attributable to RAP 

 

 Totals  Total Benefits  Total Costs  Total Net Benefits 

Case CostsBenefits

Variables: Functional Model

• Service costs• Data costs

Protocol

Upper model: Trace provenance of data Functional model: Interviews at generic

level Database model: Review database

schemas Result:

Trace data from creation to storage to outcome, along with costs: Interoperability model

Articulate benefits (as represented by the data)

ROTI, SROI:Based on nef, 2006 Understand and

plan Stakeholders Boundaries Impact map,

indicators SROI plan

Collect data Projections Analyse income,

expenditure Calculate SROI Report <Cycle>

Nef=New Economics Foundation (UK)

Questions Raised

What are the IT decisions that matter? How far can we get with generic data? Issue of monetizing the “upper model”

outcomes The biggest costs for the system as a whole

are from NICU stays for premature babies. But those costs are not in our universe.

“Minimal modeling” (David Meltzer): Value × Durability × implementation × incidence × population.

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What are the Markers of Success?

A seamless integrated Health and Human Services environment

Integration at the point of intake and assessment

Integration at the point of service delivery

Collaborative case practice when case acuity is severe

Improved client and patient outcomes

A more equitable service delivery system

Strong population health and program level data and analytics capabilities in addition accessible case specific data

38Uma S. Ahluwalia, DirectorDepartment of Health and Human Services | Rockville, Maryland 240.777.1266 | uma.ahluwalia@montgomerycountymd.gov

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