All over the country, human service organizations are working together to coordinate care for individuals and improve the overall wellbeing of communities. This is no easy task because the needs of individuals and communities widely differ and are constantly changing. Technology plays a key role, but people who are dedicated to helping individuals by addressing the all the social determinants of health are the ones who drive innovative solutions.
This week we announced that we have partnered with the Philadelphia Office of Supportive Housing in their innovative efforts to help individuals experiencing homelessness in Philadelphia. We are proud to work with them to drive these critical outreach programs and improved coordination of care and services.
We also want to take some time to highlight two of our clients who have truly looked for innovative ways to use ClientTrack to help people improve the wellbeing of people in their communities: Utah HMIS and AIDS Help of Monroe County.
Utah is well known for being the first state to adopt a statewide Housing First initiative and dramatically reducing homelessness. Beginning in 2005, the Utah Housing First initiative focused on reducing homelessness by improving coordination between all the different service providers and stakeholders in the community. Utah HMIS is a driving force behind the state’s successful Housing First initiative. Patrick Frost, Director of Utah HMIS, said “We have made great strides using the ClientTrack coordinated assessment tools to identify the most vulnerable homeless individuals and create care plans for them. Having a statewide case management system helps us track individuals across the state and get a complete picture of what it will take to end the person’s homelessness.”
Prioritizing Unique Homeless Sub-populations
Utah has made great strides using coordinated assessment to prioritize people who are the most vulnerable and find ways to make their Housing First initiative inclusive of several homeless sub-populations. A unique sub-population they have been able to include in their Housing First process is the Domestic Violence service providers. By law, there can be no identifying client records for survivors of domestic violence. This can make it tricky to add survivors of domestic violence to service priority lists.
Utah HMIS created an innovative solution where a survivor of domestic violence is assigned an anonymous identifier in the statewide HMIS database and then, based on their assessment, they are added to the housing priority list. According to Ashley Tolman, Special Projects Manager for the Utah State Community Services Office, “We’ve really taken on the task to pull our state service providers together to pull our statewide Utah Domestic Violence Coalition and HMIS team to determine how we can integrate them into this process. The individuals (through their alias) show up in the exact same housing priority list as anyone else so they are not excluded in any way from accessing those services.”
AIDS Help of Monroe County
Many individuals with HIV/AIDS deal with multiple issues, including poor medical health, behavioral health, and homelessness. Since 1986, AIDS Help has worked to coordinate compassionate medical care and social services for people with HIV/AIDS. AIDS Help works to address the social determinants of health that affect individuals with HIV/AIDS and coordinate their care with other community providers.
Managing a diverse group of patients whose needs span across different programs is no easy task. By 2014, the success of AIDS Help and the expansion of their services lead to the need for a software solution that could help streamline patient care coordination, reduce costs, and grow with their organization.
New patients come to AIDS Help from multiple sources, including the Monroe County Health Department, local clinics, as well through their year-round HIV testing outreach services. In order to improve health outcomes for the new patients and identify possible barriers to care, staff at AIDS Help conduct a comprehensive assessment within 72 hours for individuals with newly-identified HIV. The case worker enters patient information in the ClientTrack intake to quickly determine eligibility and then creates a unique care plan that includes housing, medical health, behavioral health, employment, and medication.
Mobile Case Management
An essential part of the vision of AIDS Help Monroe County is taking the services they provide and taking them to individual’s homes. Esneider Gomez, Director of Quality Control for AIDS Help of Monroe County, said “We were doing home visits before we moved to ClientTrack, but everything on the intake form was filled out manually and then we did data entry later. Now we can quickly enter all of the patient information in ClientTrack Mobile and then use Query Builder to pull reports.” The staff at AIDS Help work to ensure collaboration among all providers who coordinate care to address all their patients’ needs. Costs go down while the patient’s overall health and wellbeing goes up.
Utah HMIS and AIDS Help of Monroe County are just two of many human service organizations who are working to provide innovative solutions for the people in their community. We are proud to partner with a variety of organizations to use data and technology to connect people with the right services.
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