Persona: Robert Lanton

Life Situation: Robert is a 29 year old male ex-Marine, who is presently homeless after returning from three tours of Iraq.   He has been diagnosed with post-traumatic stress syndrome (PTSD).  During his tours, Robert witnessed the truly horrible and violent acts of war.  His experience of the death of his comrades and his own near-death experience has challenged his coping skills.

He has a “fiancée”, Kathy that he returned to after his discharge.  They have a two year old daughter together.  They were both joyous on his safe return.  Soon after his return, Kathy found it difficult to adjust to Bob’s bouts of depression and felt useless in trying to comfort him as he stayed up late trying to ward off horrible nightmares that sometimes caused night terrors. After a particularly bad encounter with Kathy, she told him in anger to leave.  He left and has been homeless since…

Quote:  “It’s just that hugs and kisses cannot take away what I saw or feel today.  I love Kathy and my daughter but I just cannot move away from the past...so I have moved away from them.”

Useful links: Mural

Connecticut Department of Social Services Strategic Action Plan

Topic: Action Plan
Event: Stewards-led development of strategic action plan for CT Department of Social Services (October 2017 – December 2018)
Stewards of Change designed, developed and helped the CT DSS implement a strategic action plan, as required to qualify for federal funding to build a new state Medicaid Management Information System. This mural is the culmination of that yearlong process; it has been used to help senior leadership refine their vision and mission, as well as to develop overarching annual agency goals.

Useful links: Mural

The Role of Social Determinants in Healthcare

Topics: Interoperability Journey Vision, SDOH
Event: Community Information Exchange Summit, Driving Cross-Sector Collaboration and Data Sharing to Create Healthier Communities (April 24-26, 2019)
Session: Shifting the Health Care Paradox
Keynote speaker Lauren Taylor presented and explored key themes from two works she co-authored, “The American Health Care Paradox: Why Spending More is Getting Us Less;” and “Social Determinants as Public Goods: A New Approach To Financing Key Investments in Healthy Communities.” This mural captures her key points and illustrates the impact and importance of data-sharing and interoperability to implement integrated, whole-person care.

Useful links: Mural

Diversity and Equity in Health and Human Services

Topics: Interoperability in Action, Diversity and Equity, Race Equity
Event: Community Information Exchange Summit, Driving Cross-Sector Collaboration and Data Sharing to Create Healthier Communities (April 24-26, 2019)
Session: Why Health Equity Matters
This interactive (and sometimes provocative) panel discussed how adopting a racial equity lens can inform local efforts to enhance care coordination across human services, social services, and health. This mural reflects their conversation, which highlighted the importance of addressing race and health equity as part of changing systems and moving toward more-effective, multi-generational, whole-person care.

Useful links: Mural

Connecting Health and Healthcare for the Nation: A Shared Nationwide Interoperability Roadmap

Topics: Interoperability Journey Vision, Office of the National Coordinator Federal Keynote
Event: SOCI 10th Annual National Symposium: Harnessing the Power of Information Interoperability and Social Determinants to Advance Health and Wellness Integration (June 22-24, 2015)
Session: Insights on ONC's Nationwide Interoperability Roadmap
Underlying the Affordable Care Act's "Triple Aim" (improving the quality, cost and patient experience) were the objectives of person-centric practices and interoperability. Yet, after a decade of nurturing these goals, there were only a limited number of examples of system interoperability within HHS. In its 10-year "Connecting Health and Health Care” plan, the Office of the National Coordinator for Health Information Technology described 11 federal actions to help drive demand for interoperability. Signaling the end of ONC's narrowly focused HIE policies, this draft roadmap invited the convergence of diverse stakeholders, external forces and interests to collaboratively lead and govern the HHS ecosystem. The presenters shared their perspectives on the promise and challenges of advancing interoperability and incorporating social determinants.

Useful links: Event | Video | Mural

Vision Roadmap: Montgomery County Maryland

Topics: Interoperability Journey Vision, Montgomery County MD
Event: Stewards-led development of a “change vision” for Montgomery County (MD) Department of Health and Human Services (May 19, 2009)
Stewards of Change planned and facilitated a daylong session with Montgomery County officials to create a unified “change vision.” This mural shows significant elements of the process and the resulting vision, which has been used to further broad communication of the department’s integrated services strategy and to guide the development of enabling information technology.

Useful links: Mural

Community Information Exchange | San Diego County, CA

Topic: CIE
Event: NIC New England Fall Symposium 2018: Moving Upstream to Improve Health and Well-Being (November 26-28, 2018)
Session: Learning from Innovation and Success in San Diego
2-1-1 San Diego’s leaders discussed their Community Information Exchange (CIE), an ecosystem of multidisciplinary network partners that is shifting how health and social service providers deliver person-centered care and contribute to individual longitudinal records through shared language and outcomes. They described the CIE’s evolution in collaboration with San Diego’s HIE and the county ConnectWell to improve health equity and outcomes across systems of care.

Useful links: Event | Session presentation | Mural

Moving from Theory to Reality in Baltimore and Oakland

Topics: Interoperability in Action, Examples of Interoperability Implementations, Moving from Theory to Reality in Baltimore
Event: SOCI 10th Annual National Symposium: Harnessing the Power of Information Interoperability and Social Determinants to Advance Health and Wellness Integration (June 22-24, 2015)
Session: A Baltimore Case Study: Moving from Theory to Reality – Understanding the Relationship among Social Determinants, Racism and Structural Inequities to Improve Health, Wellness and Safety
Given the unrest in the event’s host city, and the attention it received, this session identified practical solutions to help Baltimore move forward – and to assist other communities across the nation facing similar challenges. The panel discussed how policymakers and practitioners could better use data to understand the underlying causes of poor health and discontent to inform more-effective decision-making and policy-making. Fundamentally, this session addressed how we can better use data to guide interventions and understand the relationships among social determinants, racism and structural inequities related to both poor health and violence. Insights, challenges and solutions discussed during this session informed symposium recommendations.

Useful links: Event | Video | Mural

Bridgeport Prospers: The Baby Bundle Moving Upstream from Birth to Three

Topics: Interoperability in Action, Examples of Interoperability Implementations, Bridgeport Prospers Baby Bundle
Event: NIC New England Fall Symposium 2018: Moving Upstream to Improve Health and Well-Being (November 26-28, 2018)
Session: Bridgeport Prospers, Baby Bundle: Moving Upstream from Birth to Three
The presenters provided an overview of this ambitious, multi-domain initiative that is bringing together early education, hospitals, schools, public safety and other relevant Department of Social Services programs to improve the lives of infants, children and families through early detection and intervention. Discussion about this innovative initiative, on which NIC is working with the key players on the ground, focused on key insights and how “Baby Bundle” can be shaped and implemented not only to benefit the struggling community it is intended to serve, but also so that it can become a pilot for replication across Connecticut and, perhaps, far beyond.

Useful links: Event | Session presentation | Mural

Enterprise Systems-of-Systems Thinking for Health and Human Services

Topics: Interoperability Journey Vision, Systems of Systems Engineering
Event: Achieving Interoperability: Implementing Solutions to Connect Health and Human Services (June 10-12, 2013)
Session: The Big Picture: Enterprise Systems Thinking for Health and Human Services
The concept of a “System of Systems” was introduced as a model to address the highly complex task of building interoperable systems to deliver results greater than the sum of the individual systems. Massive system integration and interoperability efforts began to take root across the health and human service field, fueled in large part by the Affordable Care Act, which provided new investments, administrative flexibility and a drive for innovation. As leaders across the government and private sectors faced these uncharted territories, serious considerations arose about how to plan, manage and optimize change efforts at an unprecedented scale. Systems of Systems thinking provided a conceptual framework for HHS to consider how to manage a wide array of existing and new systems so they can interoperate more effectively and efficiently.

Useful links: Session presentation | Mural

Vision Roadmap: Administration for Children and Families

Topics: Interoperability Journey Vision, Administration for Children and Families
Event: Visioning Session at the Administration for Children and Families, US Department of HHS (March 15-16, 2010)
Session: Administration for Children and Families Visioning Session with Senior Leadership Team
ACF’s two-day Change Vision work with SOCI was designed to create a unified “change vision” and preliminary “roadmap” to facilitate broad-scale communication of the agency’s integrated services strategy, as well as to guide the planning, development and implementation of interoperability throughout ACF and across other federal agencies. One outcome was greater organizational alignment around a mutually agreed-upon future. This “To Be” state was used as the standard to evaluate business processes and determine appropriate new ones. It was also useful for planning organizational changes. It provided a shorthand language that enabled staff to literally “see” the vision, interact with it and discuss integrated services, new processes and organizational values.

Useful links: Mural

National Roadmap for Implementing InterOptimability

Topics: Interoperability Journey Vision, Human Services 2.0 – InterOptimability
Event: SOCI 4th Annual National Symposium, Implementing InterOptimability: From Theory to Practice (January 19-21, 2009)
Session: Actualizing Customer-Centric Health and Human Services
This session focused on designing a national roadmap for building a person-centric, connected health, education and human services system that could expediate the process of breaking down silos and creating connections across them. The SOCI InterOptimability model was used to guide the process of how organizations could integrate and optimize their capacity to learn, plan and leverage interoperability – and identified the implications and considerations for individuals, communities and organizations.

Useful links: Session presentation | Mural

The Role of Research and Analytics to Improve Lives of Children and Families

Topics: What’s Next, The Role of Research and Analytics to Improve Lives
Event: A Symposium in The NIC of Time: Advancing Information-Sharing in California and Beyond (March 26-27, 2018)
Session: The Art of the Possible: Precision Human Services
“Person-centered care” is being refined and redefined as a result of innovative information-sharing initiatives in California and around the country. Today, the goal is not only to ensure that every individual’s specific circumstances are being addressed holistically, but also to integrate the gamut of available data relating to the social factors that impact health and well-being. This session explored promising near- and longer-term opportunities to improve the way our systems share information and deliver care more effectively and efficiently.

Useful links: Event | Video | Mural

Privacy and Confidentiality: Getting to Yes!

Topics: Interoperability in Action, Examples of Interoperability Implementations, Privacy and Confidentiality
Event: California HHS Interoperability Symposium (May 21-23, 2013)
Session: Getting to Yes!
Presentations and discussions focused on innovative practices and projects from California that were enabling information-sharing, while respecting confidentiality, privacy rights and security. The focus was “getting to yes,” rather than discussing barriers. Panelists shared recent efforts, successes and ongoing projects in the areas of health, public assistance, child welfare and courts. The panel presented promising approaches and technologies; table discussions then focused on the processes and impact of expanded data-sharing, including questions relating to initiatives such as Health Information Exchange, Electronic Health Records and changes to the Affordable Care Act.

Useful links: Mural

Employing Cognitive Computing to Improve Program Effectiveness

Topics: Interoperability in Action, Technology and Data, Cognitive Computing and Child Welfare
Event: SOCI 11th Annual National Symposium: Interoperability in Action: What’s Working Now – and How We Can Shape the Future (June 13-14, 2016)
Session: Innovation Spotlight: Employing Cognitive Computing to Advance Program Effectiveness
This presentation explained how cognitive computing is helping to turn information into actionable knowledge, and explored the future of this promising technology. Examples of current usage were drawn from the realms of health care and human services across the nation and the world, including the potential impact on child welfare outcomes. The speakers also discussed the potential impact of cognitive computing to revolutionize our thinking and our approach to knowledge management, decision-making and harvesting vast information from across networks.

Useful links: Event | Video | Session presentation | Mural

Advancing and Sustaining Progress: The View from the Top

Topics: Interoperability in Action, Governance and Leadership, Advancing and Sustaining Progress
Event: NIC New England Fall Symposium 2018: Moving Upstream to Improve Health and Well-Being (November 26-28, 2018)
Session: The View from the Top I: Advancing and Sustaining Progress from the State Perspective
What innovations, processes and changes are needed to integrate the social determinants of health and well-being upstream into the HHS ecosystem? In this session, HHS leaders from NIC’s three inaugural partner states discussed specific ways they had sought to answer that question, the successes they’d had, the challenges they’d faced, and the times they’d wished they hadn’t come to the office. A primary focus of the conversation was the strategies and programs they had used to instigate change and what they’d learned about replicating, scaling and sustaining it.

Useful links: Event | Mural

The Opioid Epidemic: A Case Study

Topics: Interoperability in Action, Opioid Epidemic Case Study
Event: SOCI 11th Annual National Symposium: Interoperability in Action: What’s Working Now – and How We Can Shape the Future (June 13-14, 2016)
Session: Case Study: Battling the Opioid/Heroin Epidemic with Better Information-Sharing and Interoperability
This session used a case study methodology to engage participants in discussions that addressed a national epidemic that is affecting virtually every community in the nation, i.e., the opioid addiction and heroin crisis. Participants explored the impact of the crisis in general, and also focused on the immediate and long-term effects on health and human services programs. In particular, panelists explored the ways in which better information-sharing and technology could improve upstream prevention efforts and early Intervention strategies.

Useful links: Event | Video | Session presentation | Mural

Diversity and Equity in Health and Human Services

Topics: Interoperability in Action, Diversity and Equity, Race Equity
Event: NIC New England Fall Symposium 2018: Moving Upstream to Improve Health and Well-Being (November 26-28, 2018)
Session: Can the Solution be Right if the Data is Biased?
Implicit bias and institutional discrimination are important factors that help to shape research, policy and practice. This session examined the role of these “invisible social determinants;” why they should become integral elements of reform efforts; and specific steps for making progress. The presenters also addressed this central question: How do data-integration platforms and strategies functionally do no harm? This question acknowledged that tools that create pathways to accelerate data-sharing and system interoperability inherently have the capacity to “profile poverty,” codify racism and engineer disadvantage.

Useful links: Event | Session presentation | Mural

Persona: The Garcia Family

Life Situation: Ms. Garcia is a 40 year old Latina widow, who lives in a rural part of her county, approximately 50 miles from a metropolitan area. She is on a fixed income with disability due to a car accident. She has temporary custody of her granddaughter, Angelina, age two years, and receives foster care payments for her granddaughter.

Her daughter, Marisol, 20, lives in the city and infrequently contacts her mother or daughter. Ms. Garcia asks her daughter to return to live with her and her granddaughter whenever there is contact. Ms. Garcia has recently been told by her granddaughter’s social worker that parental rights termination proceedings will begin on her granddaughter. If Ms. Garcia does not begin proceedings to adopt Angelina, Angelina would be “removed” and placed adoptively with strangers. Ms. Garcia does not want to give up on her daughter by instituting adoption proceedings; she wants to be a grandmother only, not a grandmother/mother. But she has not heard from her daughter in more than seven months. Ms. Garcia knows that Marisol is at risk but…

Quote: “I just want my daughter to come home...I know that she has problems but being pregnant again means that she might be more willing to finally do something. Angelina is such an adorable and sweet girl. I know that Marisol would see this...there is always hope.”

Useful links: Mural

1^st National Human Services Vision

Topics: Interoperability Journey Vision, National Vision
Event: SOCI 3rd Annual National Symposium, Preparing Child Welfare for the 21st Century Information Technology Revolution (October 31, 2007)
Session: InterOptimability Visioning and Planning
During the symposium, attendees representing a wide range of programs and sectors worked to draft the first Human Services Vision Mural. This effort delved into the core considerations, challenges and opportunities that were resonant in their communities, organizations and the broader HHS ecosystem. A wide range topics were discussed, including how to build resilient partnership structures to improve collaboration, focus on consumer-centered care and build supportive governance to support human services integration and technology advancements.

Useful links: Session presentation | Mural

Persona: Antwon Baker

Life Situation: Antwon just turned twenty years old. He left foster care on his eighteenth birthday, “emancipating himself” after having been in eleven foster families from the age of eight. He had wanted to be “on his own” since he can remember and typical of many young people in foster care, sought out his birth mother. She let him sleep on the couch but could not provide him with support financially or emotionally. She was very young when she had Antwon and she is now struggling to keep his two younger half-brothers in her home. She asked Antwon to leave when he kept coming home late hours after “partying” with friends. Antwon also tried to find his father through his paternal grandmother, but was rebuked when the contact was made…

Quote: “I just want to be able to get my life together. I don’t want to be told what to do I just need some help to get things going again. I just wanted to be on my own when I left my last foster home. It has been harder than I thought that it would be...I just do not want to end up on the streets.”

Useful links: Mural

Applying Social Determinants to Improve Health and Wellness

Topics: Interoperability Journey Vision, SDOH
Event: SOCI 10th Annual National Symposium: Harnessing the Power of Information Interoperability and Social Determinants to Advance Health and Wellness Integration (June 22-24, 2015)
Session: Applying Social Determinants to Improve Health and Well-Being
As millions of people gained access to health care coverage, the opportunity and need to learn about the role of the Social Determinants of Health and Well-Being became more pressing than ever. This session provided a foundational understanding of the social determinants, as well as the implications for redesigning systems that consider the impact on population health outcomes and on individuals in the context of their resources, living environments, families and communities. We also explored the progress and promising practices relating to the rebalancing of investments when social determinants are included, as well as the challenges of this more-integrated approach.

Useful links: Event | Video | Video | Mural