After roughly two years' work, Sonoma County officials are ongoing in a solution deployment aimed at strengthening the county’s safety net, helping those most at risk by connecting them to services they need — and driving operational efficiency.
The goal, department heads and the county Board of Supervisors decided, was to identify the area’s most vulnerable, high-needs residents and eliminate silos in the way of their service – facilitating the secure, anonymized data-sharing that could help accomplish this.
“We could get better outcomes for clients and certainly reduce a lot of the cost for the county and for the taxpayers," said Carolyn Staats, county director of innovation and IT manager for the Accessing Coordinated Care and Empowering Self-Sufficiency (ACCESS) Sonoma County initiative. "For that approach to sharing data, essentially, it would require sponsorship. So, the Board of Supervisors (BoS) made strengthening the safety net – that’s what they called it – ... a priority for the County of Sonoma.” The county’s departments of health services, human services, probation, child support and housing; its community justice commission; and its public defender, courts and sheriff’s and district attorney’s offices were among those that joined the discussion.
• Buy-in was key. Officials from the departments began meeting monthly in 2017 to discuss what they wanted in a safety net that could be accessed in a secure fashion by multiple agencies and enable a single pane-of-glass view. They agreed that a lot of resources were expended on so-called “frequent flier” residents and because their siloed systems didn’t work together. A BoS resolution in November 2017 gave officials the authority to create a county source system that “would be a data hub repository” for active clients with siloed systems, Staats said. A team comprised of representatives from each agency involved helped guide the project.
“The key is having access to a 360 view," said Sonoma County Department of Health Services (DHS) Director Barbie Robinson. "What’s exciting for us is, while we started with this interdepartmental team collaborating together for high-needs, intensive-needs individuals, once it’s in everyone’s department, we’re able to have our staff think about the care they provide to folks in a more holistic way. Whether they’re high needs or not,” The new system’s first cohort, in fact, wasn’t the region’s homeless; it was victims of the recent wildfires.
• The system, which utilizes the IBM Watson Care Manager and IBM Health and Human Services Connect360 tools, is still a work in progress. Sonoma County was able to base its architecture on schema from a previous endeavor by San Diego County, which had designed a tool centered on one agency that allowed access for community partners. Sonoma County is smaller, serving around half a million residents with around 4,200 employees; and another key difference was that its solution would connect multiple agencies.
Following a DHS procurement, the county began working with the successful vendor, IBM, in April 2018 in an agile format. By the end of July, officials had created the ability for clients in mental health, substance abuse, DHS and probation to work together and taken the system live. The initiative’s second phase tackled challenges including integrating housing data and designing data interfaces. Its third phase, ongoing and likely to wrap later in mid-summer, includes development of a mobile, cloud-based consent form for client data. The fourth phase, which should last until year’s end, aims at working with individuals from the criminal justice system who may have behavioral challenges; and circling in frequent emergency-room utilizers.
• ACCESS’s delivery is already being recognized. On May 7, Sonoma County received a 2019 Advantage Award from IBM Watson Health, in the Consumer/Patient Outreach and Communications category. On April 29, the agency was notified it received the National Association of Counties’ (NACo) 2019 Achievement Award in the area of health, for improving its service.
“The one thing we’re looking for is innovation -- Is this serving residents in an innovative fashion? -- and it certainly is,” NACo Communications Director Paul Guequierre told Techwire.
• A state partnership could be coming, Robinson told Techwire. Officials are exploring taking part in what’s called the Section 1115 Demonstrations – pilot or demonstration projects approved by the federal secretary of Health and Human Services but centered in California.
“I meet with other counties regularly and they’re very excited about the work that we’ve done," Robinson said. "And one of the things that we would want to do is to pitch this to the state as part of maybe the 1115 waiver program and Medicaid to do data integration. Recognizing, if you’re really going to be effective, you have to think about the person holistically.”
Stakeholder engagement for the 2025 federal funding waiver begins this summer.
