Enhanced Care Coordination
We are a nonprofit technology and collaboration catalyst that works with a wide range of partners in San Diego County to transform care delivery. With initial funding from an Innovation Grant from Alliance Healthcare Foundation, CIE is strengthening the governance structure, developing the leadership, validating demand amongst collaborative partners, and defining business and technical requirements to effectively and safely share sensitive data across stakeholders in the social and health services arena.
The following organizations are active in the CIE network and others will be added soon. Beginning in July 2014, these organizations will be able to view client information from multiple organizations to enchance care coordination:
Clients may change or revoke (opt-out) their authorization to participate in the CIE network by contacting any Participant organization or sending an email (with "opt-out" in the subject line, include full name, date of birth, and gender) to OptIn@CIESanDiego.org.
Information silos hinder care coordination
Throughout San Diego County, many of the more than 9,000 nonprofit organizations are serving the same people; each organization approaches the underserved with their own lens and services. Those most in need often have complex and interrelated needs including difficulty self-navigating multiple programs and organizations. Without efficient systems to allow care managers to â€œtalk to each otherâ€ across program silos, it is nearly impossible for care givers to coordinate care on behalf of their clients.
To manage chronic disease, to prevent readmissions to hospitals and emergency departments, and to focus on health — not just healthcare — requires social service and other care providers to effectively share information and coordinate their efforts. But the technology, processes, and trust have a long way to go to reach the ideal of seamless care coordination.
Information sharing provides a 360° client view
We build and operate trust networks “ including software, people, and processes. Through sophisticated technology that manages trust agreements, we enable the exchange of information across organizations in real-time and provide partners with a more comprehensive view of the needs and services individuals they serve have received. As a result of transforming care delivery coordination, care can become easier to navigate, less expensive to provide, and more effective.
Historical awarenessWhen an individualâ€™s history is understood more fully, better coordination can improve future decisions.
Consent-Based SharingClient privacy and confidentiality are critical to our trust network, so all sharing is based on client opt-in.
Population health managementHealth is more than episodic healthcare. Through analysis of social service variables, researchers can discover patterns that help drive better policies
Coordinated careWhen common client information is shared across organizations, care transitions can be smoother, efficiencies can be greater, and costs can be lower
Eventually, we aim to serve the majority of San Diego County social service nonprofits to provide innovative client-centered services. We will add cohorts of partners in phases based on the value we can create together. If you have ideas about improving care coordination, let's talk.
HomelessOur first â€œuse caseâ€ is helping those who serve homeless people. They spend precious time piecing together each clientâ€™s history and needs. And often waste hours duplicating solutions that other service providers already provide. Initial Partners include: Downtown homeless service providers, San Diego Police HOT (Homeless Outreach Team), San Diego Emergency Medical Servicesâ€™ Resource Access Program (RAP), 2-1-1 San Diego
ElderlyOrganizations serving the elderly often see only a select part of the complex network of needs that contribute to that individualâ€™s overall health. CIE aims to make meaningful connections across - social, physical, mental, and environmental lenses.
YouthYouth serving organizations often depend on case managers or other adults to identify and fulfill care gaps. CIE aims to build bridges across otherwise fragmented delivery programs to enable more seamless, person-centric services.
Seamless care coordination improves health outcomes