360˚ Community Coordination

2-1-1 San Diego is building a new technology ecosystem meant to bridge service delivery gaps for clients. We have spent more than 10 years serving 1.5 million clients and have identified ways in which we can improve our service delivery. We know that many clients have the potential to fall through the cracks and may not access the resources they were directed to. This is a common challenge for many of us working in the social services sector.

What is 360° Community Coordination?

It’s an exciting time for us because we are creating a proactive, preventative solution. We need your help! We invite you to help us build our 360° Community Coordination platform.

  • This system will give each partner an interactive shared Salesforce client record that will provide a longitudinal view of services received. This record will give you an in-depth understanding of their history, allowing for a holistic, 360° view of that client’s needs, past and current referrals, and outcomes.
  • Participating partners will have access to shared client information, providing a complete view of how each service provider is helping each client. This will foster formal relationships with local service providers and allow you to work closely together to ensure that each client’s social determinants of health are being improved thoroughly and accurately.
  • This system will allow for proactive and agile care coordination because you will receive real-time feedback reports from other participating partners who have provided services to your client.
  • Working collaboratively within one ecosystem will give you high-quality, actionable data through shared individual client records with outcomes that indicate unmet needs, as well as your organization’s impact on each client’s health and social functioning over time.

 

Using Community Information Exchange (CIE) as a small scale, and highly successful, example of how to build out and implement a collaborative care coordination system, we are working to scale this example up to embrace all sector partners.  We hope you’ll join us in building this collaborative system and work with us to continue to best serve our clients and help them achieve happy, healthy, self-sufficient lives!

For more information, please email us at info@211sandiego.org

Current participants can access their resources here

Community Information Exchange, a technology of 2-1-1

When our clients use 2-1-1, the critical issues are knowing if the services they are referred to meed their needs, and if the agencies providing those services are working together to improve each client’s outcomes. We have piloted a community coordination tool, Community Information Exchange (CIE), that had dramatic client improvements such as:

    • 42% reduction in unnecessary ambulance transports.
    • 44% improvement in housing stability

 

What is CIE?

CIE helps the underserved get the help they need, when they need it, by facilitating seamless care coordination that improves client health and social outcomes. We do this by enabling the near real-time capture, exchange, and analysis of client-specific social service data across many organizations, providing a 360° visibility of a client and their past, present, and future care.  This clarity in the client experience helps create the context health and social service workers need to deliver better, more efficient care.

Used by a wide range of social service case managers at community-based organizations (CBOs) during intake and care transitions, our online client-specific dashboards aid staff to better understand client history and needs. This information is used by:

  • Hospital Planners to reduce length of stay of patients and to define realistic care plans for extended or aftercare.
  • EMS and Ambulance Personnel to reduce unnecessary transports and hospital emergency department visits.
  • Health Plan Case Managers to help with post-hospitalization assessments and coordinating preventive interventions to reduce inpatient readmission.
  • Discharge Planners to improve the process of ordering medical supplies, home-delivered meals, and transport services.

 

Current CIE Partners

CIE helps our region’s vulnerable populations by providing a better means for social service providers, healthcare service providers, and health plan providers to communicate and coordinate care more efficiently, thereby providing better outcomes for clients, patients, providers and the community at large.

  • Alpha Project
  • Catholic Charities Dioceses of San Diego – Rachel’s Women’s Center
  • ElderHelp of San Diego
  • Family Health Centers of San Diego
  • Meals-On-Wheeles of Greater San Diego
  • PATH/Connections Housing
  • Rural/Metro San Diego
  • San Diego Fire-Rescue Department, Emergency Medical Services Division, Resource Access Program
  • Scripps Mercy Hospital
  • Serving Seniors
  • St. Paul’s PACE COmmunity Eldercare of San Diego, Inc.
  • St. Vincent de Paul Villages/Father Joe’s
  • UC San Diego Health System Hilcrest Medical Center

 

CIE Collaborative Partners

  • Knowledge Integration Program (KIP) of the County of San Diego Health and Human Services Administration (HHSA), which focuses on enhancing client-centered service delivery.
  • Regional Task Force on the Homeless (RTFH) the Homeless Management Information System (HMIS) lead of the Regional Continuum of Care’s HMIS system.
  • San Diego Health Connect (formerly Beacon HIE) the regional Health Information Exchange, or HIE, which focuses on medical record interoperability.

 

Current participants can access their resources here

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