Whole Person Care in Contra Costa

There’s often a lot more to a person’s health than just what lab tests or medical records say about them.  In fact, we’ve written in the past about the importance of social determinants of health as it related to complete care.  Thoughts like this are what lead California’s Department of Health Care Services to create a pilot program called WPC, or Whole Person Care, that aimed to see how harmonizing social services with physical and behavioral health can not only affect patient outcomes, but also manage the cost of care.  The program is offering pilots that are funded by up to $1.5 billion in federal money over five years which is matched by local funds.

Contra Costa Health Services turned out to be a great match for the pilot as they had a disproportionately high number of patients with social needs, a full 50% of those admitted to their clinics.  With a large number of residents living below the poverty level, and a high rate of overcrowding for low-income renters, Contra Costa’s pilot program aimed to create scalable services for some of the most vulnerable patients.

Contra Costa will receive $200 million in total from 2016-2020 to remove walls between their data, giving a more complete picture of patients while automating time-intensive processes.  The plan was to make this data collaboration occur through their EHR, Epic.  While Contra Costa had implemented Epic for things like their ambulatory clinics, the WPC funding would allow them to use Epic with their social case management program, behavioral health, and a county-wide data warehouse.  SmartForms were also developed to incorporate information from outside partners, such as legal professionals, transportation coordinators, and cellular companies.

The implementation allowed for a completely automated process identified the top eligible patients for the WPC program based off of things like their likelihood of having an avoidable hospital visit.  It then automatically enrolled those classified as high-risk and assigned them a case manager.  The information that they collect is entered into Epic, including using tools that Epic developed specifically for this program.

With an individual case manager’s patient load reaching into the hundreds, it was also important to give them functional dashboards to better prioritize their time and easily serve the patients they’re working with.  Having this up to date information allows case managers to stay on top of patient activities like admittances and discharge instructions.

So far, the program has been effective in providing aid for some of the county’s most vulnerable residents.  Providers are better able to treat patients with a full picture of their behavioral health, housing situation, and more.  Those enrolled are getting better access to housing assistance, better care, and are getting more immediate help with restoring lapsed Medicaid coverage that they may not have even been aware was needed.

All of this is occurring with a reduction in manual work, with hundreds of hours saved per month.  The key to better patient care and operational efficiencies is through better data that is more readily available for providers.  If you’d like to find out how Extract helps healthcare organizations with their incoming data, please reach out today.