For the homeless, a government they can count on

“We’re dealing with a population with complex needs.”

By | 4 minute read | March 12, 2019

California resident Sandy Beech* was seeking a fresh start in Sonoma County when she moved from Santa Cruz in 2017. Her son, struggling with substance abuse, had become threatening towards her, and she feared for her safety.  But she was unable to find affordable housing, and soon began living in her car. That exacerbated existing, chronic health problems, for which she sought treatment in an emergency room. She also experienced behavioral health issues.

Barbie Robinson, Sonoma County Department of Health Services Director

“Sandy is representative of the population we’re trying to serve,” said Barbie Robinson, Sonoma County Department of Health Services Director. “She faced a number of life challenges. She was homeless, with mental and physical health challenges.”

Though Beech had received services from agencies in Santa Cruz in the past, she wasn’t able to connect with Sonoma County’s support systems. Learning about the various systems available to her—and registering for them—proved a challenge.

“We’re dealing with a population with complex needs,” Robinson said. “Individuals fall through the cracks, and we see poor outcomes and poor experiences in accessing government programs and services.”

At the time, the Sonoma County Board of Supervisors was working on a better way to address the needs of residents like Beech. Their program to strengthen the safety net system—Accessing Coordinated Care and Empowering Self-Sufficiency—was made a top priority. The county began forming multidiscipline teams (IMDTs) with the ultimate goal of holistic services for those in need.

“We started looking at the most vulnerable individuals in Sonoma County,” Robinson said. “We’d already started conversations with IBM. We were beginning to look at data, and the wildfires hit.”

Drone footage of Sonoma County after the 2017 Sonoma Complex Fires

The Sonoma Complex Fires struck the county in October 2017. The fires burned 36,000 acres, destroyed thousands of buildings, mostly homes, and killed 22 people. To escape the smoke, Beech found her way into one of the many local shelters opened for those who’d lost their homes. When the shelters began closing a few weeks later, some residents were able to find places to live. But others were not, and that included Beech.

“We needed a rapid response,” said Carolyn Staats, Sonoma County IT manager. “We had to help them now. Everything had to work yesterday.”

The county worked with IBM to create a Rapid Response pilot. Powered by IBM Cloud, the solution enables—with individual permissions—data integration among agency systems. That’s crucial because government agencies are usually separately funded, with separate management and staff, facilities, budgets, and priorities. In Beech’s case, she needed services from housing, health, and many social service departments, but in the past, none of those departments had a way to see her information in any system other than their own.

The solution includes IBM Health and Human Services Connect360 with embedded Master Data Management, as well as IBM Watson Care Manager. That gives the county a 360-degree view of resident needs and status. Which, in turn, empowers the integrated multidiscipline teams to collaborate on what will truly make a difference in their clients’ lives.

“The system enables us to coordinate between case workers and substance abuse counselors and eligibility workers,” said Shirlee Zane, Sonoma County Board Supervisor. “And it can all happen rapidly, so we can get that person back on their feet again.”

Sonoma County caseworker Jessica Hetherington

Social service worker Jessica Hetherington works for the Sonoma County Health Services Behavioral Health Division. One of her challenges in the past was communication from one department to the next. To bring a resident like Beech out of homelessness meant giving her multiple levels of care in order to truly change her dynamic and empower her to be truly self-sufficient. This meant stabilizing her physical and mental health, and bridging her temporary housing needs on the way to permanent housing.

“We ended up getting Sandy permanently housed and connecting her with services there,” Hetherington said.

Beech is one of more than 90,000 residents whose profiles were part of the pilot program. Her health services mental health caseworker asked Beech whether her information could be shared across the teams during the pilot—allowing the appropriate services to be coordinated across multiple agencies.

Sonoma County and IBM are continuing to work together on identifying the county’s most vulnerable populations in order to provide them the most appropriate services. The technology is scalable, meaning it can be used as a blueprint for how other counties and states can holistically manage care for populations with complicated needs.

“We know that when one life changes, it affects the whole community,” Sonoma County Board of Supervisors’ Zane said. “And that’s really the ultimate goal: a healthier community.”


* not her real name