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 San Diego has created the governance structure, validated demand amongst collaborative partners, and implemented the business, technical and regulatory capabilities to effectively and safely share sensitive data across stakeholders in the social and health services arena.
In July of 2014, CIE San Diego launched our first client-centered dashboards for sharing information across 5 organizations focused on serving downtown San Diego's homeless population. We have since expanded to more organizations, more users, and more clients - with continued expansion in 2015.
By July 2015, CIE San Diego will go live with a second cohort of information sharing organizations who are focused on seniors in downtown San Diego who are aging in their community. Over time, CIE San Diego will expand to support organizations serving a very wide range of client populations in need of enhanced care coordination across San Diego County.
The following organizations are active in the CIE San Diego network by sharing and/or viewing client information through CIE San Diego's online dashboards. Other organizations will be added soon:
Clients may change or revoke (opt-out) their authorization to participate in the CIE San Diego 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 (1,300 of which are health or human services focused) 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 talk to each other 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 degree client view
CIE San Diego builds and operates 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 individual's history is understood more fully, better coordination can improve future decisions.
Client AuthorizedClient 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, CIE San Diego aims to serve the majority of San Diego County social service nonprofits to provide innovative client-centered services. CIE San Diego 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.
HomelessCIE San Diego's first "use case" is helping those who serve homeless people. They spend precious time piecing together each client's history and needs. And often waste hours duplicating solutions that other service providers already provide. Initial Partners include: City of San Diego Fire-Rescue Department Emergency Medical Services Division Resource Access Program (RAP), PATH/Connections Housing, Rural/Metro San Diego, Scripps Mercy Hospital, St. Vincent de Paul Villages / Father Joe's, and UC San Diego Medical Center. More participant will be added in early 2015.
ElderlyCIE San Diego's second "use case" (beginning in early 2015) will be organizations serving the elderly. They often see only a select part of the complex network of needs that contribute to that individual's overall health. For example, those who deliver meals to home bound seniors go through a 'wellness check' if a client does not answer their door. Significant resources and worrry could be avoided if they received notification from other service providers (such as ambulances) when a client is known to be outside their home. CIE San Diego 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 San Diego aims to build bridges across otherwise fragmented delivery programs to enable more seamless, person-centric services.
Seamless care coordination improves health outcomes
As a growing organization, we are always interested in connecting with talented and motivated people who want to align their career and their values. If that's you, please feel free to send us your resume and a cover letter.