Jane L Snowdon1, Barbie Robinson2, Carolyn Staats2, Kenneth Wolsey3, Megan Sands-Lincoln1, Thomas Strasheim4, David Brotman1, Katie Keating1, Elizabeth Schnitter1, Gretchen Jackson1,5, William Kassler1. 1. Center for Artificial Intelligence, Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, United States. 2. Department of Health Services, County of Sonoma, California, United States. 3. Cognitive and Analytics Practice, IBM Global Business Services, San Diego, California, United States. 4. IBM Cloud and Cognitive Software, IBM Watson Health (retired), Denver, Colorado, United States. 5. Surgery, Pediatrics, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States.
Abstract
BACKGROUND: Care-management tools are typically utilized for chronic disease management. Sonoma County government agencies employed advanced health information technologies, artificial intelligence (AI), and interagency process improvements to help transform health and health care for socially disadvantaged groups and other displaced individuals. OBJECTIVES: The objective of this case report is to describe how an integrated data hub and care-management solution streamlined care coordination of government services during a time of community-wide crisis. METHODS: This innovative application of care-management tools created a bridge between social and clinical determinants of health and used a three-step approach-access, collaboration, and innovation. The program Accessing Coordinated Care to Empower Self Sufficiency Sonoma was established to identify and match the most vulnerable residents with services to improve their well-being. Sonoma County created an Interdepartmental Multidisciplinary Team to deploy coordinated cross-departmental services (e.g., health and human services, housing services, probation) to support individuals experiencing housing insecurity. Implementation of a data integration hub (DIH) and care management and coordination system (CMCS) enabled integration of siloed data and services into a unified view of citizen status, identification of clinical and social determinants of health from structured and unstructured sources, and algorithms to match clients across systems. RESULTS: The integrated toolset helped 77 at-risk individuals in crisis through coordinated care plans and access to services in a time of need. Two case examples illustrate the specific care and services provided individuals with complex needs after the 2017 Sonoma County wildfires. CONCLUSION: Unique application of a care-management solution transformed health and health care for individuals fleeing from their homes and socially disadvantaged groups displaced by the Sonoma County wildfires. Future directions include expanding the DIH and CMCS to neighboring counties to coordinate care regionally. Such solutions might enable innovative care-management solutions across a variety of public, private, and nonprofit services. Georg Thieme Verlag KG Stuttgart · New York.
BACKGROUND: Care-management tools are typically utilized for chronic disease management. Sonoma County government agencies employed advanced health information technologies, artificial intelligence (AI), and interagency process improvements to help transform health and health care for socially disadvantaged groups and other displaced individuals. OBJECTIVES: The objective of this case report is to describe how an integrated data hub and care-management solution streamlined care coordination of government services during a time of community-wide crisis. METHODS: This innovative application of care-management tools created a bridge between social and clinical determinants of health and used a three-step approach-access, collaboration, and innovation. The program Accessing Coordinated Care to Empower Self Sufficiency Sonoma was established to identify and match the most vulnerable residents with services to improve their well-being. Sonoma County created an Interdepartmental Multidisciplinary Team to deploy coordinated cross-departmental services (e.g., health and human services, housing services, probation) to support individuals experiencing housing insecurity. Implementation of a data integration hub (DIH) and care management and coordination system (CMCS) enabled integration of siloed data and services into a unified view of citizen status, identification of clinical and social determinants of health from structured and unstructured sources, and algorithms to match clients across systems. RESULTS: The integrated toolset helped 77 at-risk individuals in crisis through coordinated care plans and access to services in a time of need. Two case examples illustrate the specific care and services provided individuals with complex needs after the 2017 Sonoma County wildfires. CONCLUSION: Unique application of a care-management solution transformed health and health care for individuals fleeing from their homes and socially disadvantaged groups displaced by the Sonoma County wildfires. Future directions include expanding the DIH and CMCS to neighboring counties to coordinate care regionally. Such solutions might enable innovative care-management solutions across a variety of public, private, and nonprofit services. Georg Thieme Verlag KG Stuttgart · New York.
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