Imagine if our health and social care systems could seamlessly coordinate together to meet all our physical, behavioral, and social needs as unique individuals. The impact of this approach to care is clear: higher-quality care, more humane service delivery, reduced costs and duplication of efforts, and better outcomes for all. Those who stand the benefit the most are those who experience complex, chronic health and social needs - especially those who are homeless in our communities.
For the past several years, one California initiative has been undertaking this challenge. California’s Whole Person Care (WPC) pilot is a five-year, $3 billion waiver program that includes 25 counties working to integrate care for specific Medicaid beneficiaries in their communities. These programs most often serve individuals who have multiple chronic conditions, as well as those who are experiencing homelessness or other social and behavioral health crises.
Charis Baz, Acting Director, Marin County HHS
|As part of our SDOH MasterClass webinar series, we recently hosted a discussion on strategies for digital success in the fight to end homelessness. Activate Care’s tools have been used in homeless service programs for years, and we were pleased to be joined in this webinar by one of our customers: Charis Baz, who serves as acting Director for Whole Person Care at Marin County Health and Human Services. Marin County has achieved a sharp decline in homelessness since 2017.|
How to move from a fractured service network to a coordinated care ecosystem
Webinar Insight: Marin’s Charis Baz shared that four or five years ago, the county’s care ecosystem was fractured, siloed, and fragmented. It was really the work that their care ecosystem did as part of Built for Zero that enabled people to come together with a common goal of ending chronic homelessness. That work predated Whole Person Care, so WPC got to come in on the wings of that success. Going into this work, they knew that the county couldn’t just automatically designate that everyone was going to work together. It took a huge amount of culture change and systems change work to get to the point now where representatives from every organization spend time coordinating efforts together every week.
To get to this point, county and community leaders took time to understand the research, which shows that housing is the answer. Unfortunately, there is truth to the view that shelter tends to make homelessness intergenerational, while permanent supportive housing is associated with all kinds of better outcomes. What really pushed Marin County to take action was that there was a lot of negative publicity about homelessness in the media at the time, which placed pressure on elected officials to do something, and helped leaders in Marin’s caregiver community speak up that they felt they were doing a lot, but it wasn’t working. This was the confluence of opportunity and crisis that allowed people to say, “Okay, we’re going to take a risk and try something totally new, which represents a fresh start in this fight.”
The other important thing to know about Marin is that the WPC program isn’t achieving these remarkable homelessness reductions on their own. They are working hand-in-glove with the coordinated entry program, which is also a coordinated community-wide effort to ensure housing goes to the most vulnerable first. WPC provides case management support, with the Activate Care platform helping caregivers share information together. Meanwhile, coordinated entry manages the list of housing and voucher availability, alongside the list of individuals who have been prioritized for housing opportunities based on their vulnerability. Ultimately how these two efforts work together is that coordinated entry provides individuals with a voucher, and WPC provides them with a case manager who helps them find a place to live and stay stable once they move in.
How a central “command center” can convene stakeholders across the community
Webinar Insight: All 25 counties and areas that are doing Whole Person Care implement it in a way that is quite specific to their region. Each county has a different program model, target population, and focus. There’s a considerable difference between counties that have their own county public hospital and county clinics, for instance, as they tend to implement WPC using those existing medical and behavioral health structures and staff. In other counties like Marin, where they do not have a public hospital or county clinics, they rely heavily on coordination with their partners in the community.
At the county level, the WPC business unit in the Department of Health and Human Services is a relatively small team, but it provides the backbone for the county-wide program. They handle contracting with community-based organizations (CBOs) such as homeless service providers and federally qualified health centers (FQHCs) that provide the case management services. The WPC business unit also provides technical assistance around operations and serves as the neutral convener for people in the caring professions from across a spectrum of agencies. Sitting in the center of this program, this “command center” team makes possible the legal and compliance permissions, the release of information (ROI), and data-sharing agreements among agencies that allow them to use Activate Care’s tools in daily operations all these different organizations.
How the fight to end homelessness continues, even in a global pandemic
Webinar Insight: Through Whole Person Care, the county was able to create a universal Release of Information that their clients sign. With data sharing agreements in place, they now exchange social services data and public benefits data and share this with the case managers from a range of different organizations. This has helped them actively cultivate a culture of collaboration and sharing, and they credit all of these program elements working in conjunction as the key to making data-sharing and collaboration the norm.
Right now with COVID, Charis Baz is grateful “that we made the investment when we did because it means I have someone on speed dial at a particular clinic who can find out who I need to talk to there when something is going on for my client who is in isolation or quarantine. Now when everybody is short on time and under a huge amount of stress, I can’t tell you how valuable it is to have this network of personal relationships, trust, and shared vision, that we can rely on when we need them.”
Activate Care is grateful to Charis Baz, acting Director for Whole Person Care with Marin County Health and Human Services for contributing to our recent SDOH MasterClass webinar, Strategies for Digital Success in the Fight to End Homelessness. For more information on Marin County’s efforts to end chronic homelessness, check out the on-demand webinar. You can also learn more from the California Health Care Foundation’s report, Catalyzing Coordination: Technology’s Role in California’s Whole Person Care Pilots.