A Data-Driven Approach to Transforming Outcomes


Health and human service organizations provide support services for vulnerable individuals in their communities. By design, these service agencies have a program-centric view of care and are primarily focused on eligibility and transactions.  As a consequence, an individual is often enrolled in programs where eligibility requirements are met, but not the underlying reasons the individual reached out to the agency in the first place. It is entirely possible for an agency to meet or exceed transactional performance metrics without providing important real-world results for their clients. Although it is important to report on this kind of transactional data to be held publicly accountable, it is also critical to keep the overall wellbeing of a client in mind.  The ability to turn volumes of data into actionable insights plays a key role in reshaping and helping human service organizations change their program-centric view of care to a more holistic view focused on improving an individual’s overall wellbeing. Three important ways technology can reshape human services organizations are: Integration, Accountability, and Analysis.


Traditionally human service organizations have existed in their silos and have not shared information with other providers. Many states and localities have recognized that effective care coordination requires sharing information between these various programs and providers. For example, Boulder County, Colorado’s Department of Housing and Human Services integrated case management tools enabling employees to coordinate care among multiple programs and easily refer individuals to other providers. In California, San Diego County uses technology to share patient data among hospitals, community service providers, and caretakers to improve patient care transitions from hospitals to home.

Program data transparency is a high priority for health and human service organizations in order to maintain compliance with government regulations. It also facilitates better communication with clients, administrators, and elected officials. North Carolina officials developed a data dashboard using existing data collected by the Department of Health and Human Services to compile metrics on monthly program performance and family outcomes. In Arkansas the Department of Human Services partnered with insurance providers in the state on a Payment Improvement Initiative to drive better provider accountability in health care. Providers and insurers receive information on the costs and outcomes of care episodes and providers are entitled to share in the savings when high-quality outcomes are achieved at below-average cost.


Data Analytics hold the potential for transforming the entire human services delivery cycle. It offers administrators and managers near real-time feedback and insights to guide organizational performance and improve outcomes in the lives of those they serve.  The traditional program-centric, transactional view of care misses this opportunity for a wide angle, whole-person view to create a coordinated care plan that will improve an individual’s overall wellbeing.

Administrators, supervisors, and case workers are responsible for understanding their clients on both the individual and population levels.  They must also track and evaluate program performance in order to maintain compliance and find ways to continually improve their programs. Data analytics enable staff to assess program performance, uncover long-term population health trends, and implement more effective services for clients.

The SoonerCare Medicaid program in Oklahoma has been successful analyzing patient data including comorbidity factors to identify individuals who are prone to poor health outcomes. With this data, managers can enroll high-risk Medicaid patients for intensive managed care programs. The AIDS Foundation of Chicago’s Community Links program has successfully partnered with a local MCO in order to identify these high risk populations and help them adhere to their care plan. This collaboration achieves the IHI triple aim of improving the patient experience, improving health outcomes, and reducing the costs of healthcare.

Powerful case management tools in the hands of an empowered case manager can help change a human service initiative from a transactional, program-centric view of care to a whole-person, coordinated view that will improve an individual’s overall wellbeing. The ClientTrack case management system is specifically designed for the collaborative, highly integrated model of care that addresses the social determinants of health and improves the overall wellbeing of individuals.

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