The Whole Person Care Program at Contra Costa Health Services in California takes a data-driven approach to addressing social determinants of health, such as homelessness, food insecurity, and transportation needs. In two years, they’ve connected over 15,000 patients with case management services. By automating the assignment of case managers in Epic, Contra Costa estimates that they save nearly 350 administrative hours each month, allowing staff to focus on patient care.
One of the goals of Contra Costa’s program is integrating health data in Epic with other data sources, such as the county’s housing management system, so a predictive model can identify at-risk individuals. Case managers work with these patients to prevent adverse health outcomes, helping patients like Amy, a 31-year-old mother of two who was experiencing homelessness.
Amy was automatically assigned to a case manager based on her substance use and ED utilization history. The case manager proactively reached out to Amy and helped enroll her in a behavioral health program, as well as place Amy and her daughters in supportive housing.
“Amy said that she felt like someone truly cared about her and that she was worth their time, a feeling she said she hadn’t felt in a long time,” said Sue Crosby, the program’s director.
Contra Costa also uses a number of other tools in Epic to power the program. For example, bulk messaging notifies patients when they need to re-enroll in California’s Medicaid program, Medi-Cal. As a result, Contra Costa has restored coverage for nearly 40% of eligible patients, with a projected savings of nearly $2 million for the Medi-Cal health plan.
“As the healthcare industry is rapidly evolving to incorporate social determinants of health, health IT strategy should evolve… [to include] information such as insurance coverage, housing interventions, [and] food insecurity,” Crosby said. “It’s critical to the delivery of better and more integrated care to patients.”
Photo caption: Amy, a 31-year-old mother of two (right), meets with her case manager, Roshawn Adams, who helped Amy find supportive housing.