The County has partnered with IBM to develop the Integrated Data Hub that brings together participant information from the County’s mental health, substance use, social services, housing, criminal justice and other siloed databases, then masters it into a singular “golden client record”. The front end of the system is the innovative technology of the IBM Watson Care Manager that gives the IMDT a 360° view of information affecting a participant’s well-being and self-sufficiency.
The Watson Care Manager brings insights from case notes front and center for the IMDT members to discuss and develop the best action plan for each individual. The system also provides care management tools that support treatment planning, goal setting, health assessment, and coordinated communication. With the 360° view of a resident’s needs, IMDT members can evaluate capacity across community providers, incorporating not just County services, but also the broad array of non-governmental services into a single plan to support our residents and literally change the way needed services are identified and delivered. The Integrated Data Hub and Watson Care Manager have been active since July 2018, and the IMDT has been using the system to care manage our most vulnerable clients with complex health, housing, economic, legal, social and environmental challenges.
The roots of this technology emerged during a design-thinking session between IBM, County frontline staff of eligibility workers, adult protective services staff, clinicians, social workers, probation officers, child support and housing specialists care coordinators from each of the Safety Net Departments and continues to evolve based on IMDT needs and user feedback. The technology developed for ACCESS Sonoma County houses client information from various Safety Net Departments into one integrated data hub. The system uses a Cloud based client care plan which allows the IMDT to access the care plan wherever they happen to be engaging with the participant. The power of the golden client record combined with the ability to access the care plan at any time and from anywhere makes this an extremely innovative approach to offering true wrap-around services.