How governments can improve safety-net programs through whole-person care

By | 3 minute read | March 5, 2020

A motorist exiting a highway sees a shivering homeless woman sitting on a crate in the pouring rain holding a flimsy piece of cardboard over her head. The driver’s instinct is to help, but they aren’t sure how. So, they might provide some quick relief like an umbrella, money or a ride to someplace warm and dry. Even with billions of dollarsallocated to safety net programs in the United States, most governments find themselves in the same position as the driver. They want to do more than solve short-term problems, but they aren’t sure how.

Social services often focus on one part of a person’s life, like food security or employment, without seeing the bigger picture. Even if the driver had given the woman a ride to a shelter, the social worker at the shelter would have a limited picture of her history. They probably wouldn’t see the emergency room visit she had for an overdose three days before or the summons to appear in court for unpaid fines. That information would certainly influence the social worker’s recommendations, but because the data is collected by various groups, stored in separate records and governed by different regulations, their access to the right information is limited.

Some governments are changing the way they work by devoting more effort to collaborating across programs to give each person an individualized bundle of services. The state of California has prioritized programs to support integrated care initiatives like the Whole Person Care Pilots, a $3B initiative funded by the state and federal government which 25 California counties are already participating in.2 They are finding that one of the best ways to help populations with multiple complex needs, like the homeless, is to reorganize services and integrate records so frontline workers can respond to a range of issues in a citizen’s life. This whole-person approach to care brings together physical, behavioral, mental and social health services to quickly address multiple needs so people can receive help for both short-term problems, like having no safe place to sleep, and long-term underlying factors, like prolonged unemployment.

One place that has benefited from this integrated approach is Sonoma County, California. More than half of the unsheltered homeless people in the United States now reside in California, and even though homelessness has gone down in most states, it has increased by 16% in California.3,4 Local governments are struggling to keep up with encampments that have popped up all across the state. In Sonoma County, a combination of rising home prices and natural disasters, including several back-to-back wildfires, has led to a surge in homelessness.

Rather than trying to face these crises with the old, fractured way of offering services, Sonoma County streamlined its intake for services through a program called Accessing Coordinated Care to Enable Self Sufficiency (ACCESS). The county formed interdepartmental multidisciplinary teams to coordinate across different agencies to identify people with multiple complex needs and provide them with the right services at the right time.

To make this coordination possible, the teams brought crucial data together in one technology platform that would help caseworkers understand the key risks and needs of each client in a single view. Working with IBM, the county built a solution that integrated data across multiple departments and agencies. They created an index for over 90,000 records and brought together critical information that was needed to generate individualized care plans, and they did it all within five months.

The progress in Sonoma County shows that connecting people to the right services doesn’t have to be a perpetual guessing game that forces citizens to navigate a maze of red tape. With an integrated and holistic approach to care, governments can provide vulnerable residents with a better chance of achieving long-term wellness that ultimately empowers frontline workers and good Samaritans to bring more of their homeless neighbors in from the rain.

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  1. “An Overview of County Administration: Appointed County Administrators.” National Association of Counties. Accessed February 21, 2020.
  2. “Counties Experiment With Linking Health Care and Social Services for Most Vulnerable” California Health Report. Accessed March 4, 2020.
  3. “California Governor Declares Homeless Crisis ‘a Disgrace.’ “ New York Times. Feb. 19, 2020. Accessed March 3, 2020.
  4. “The 2019 Annual Homeless Assessment Report (AHAR) to Congress.” The U.S. Department of Housing and Urban Development. Janurary 2020. Accessed February 21, 2020.