How data integration can help weave a stronger social safety net

Recognizing that too many people were falling through gaps in the social safety net, local government officials launched the Sonoma County Safety Net Collaborative. The County also formed integrated multidiscipline teams (IMDTs) consisting of members from safety net departments including Health Services, Human Services, Child Support Services, Probation, District Attorney, Public Defender, Sheriff’s Office and the Sonoma County Development Commission. These organizations worked together to provide integrated services for clients in need.

“One of the challenges in serving the homeless population is coordinating services,” says Rivera. “Our teams do a great job with connecting with unhoused people, but when you connect in the field, it isn’t just one touch. There has to be a commitment to going out and serving clients over and over again, especially those who are chronically homeless.”

Just like many other governments, Sonoma County had a siloed organizational structure, which impeded information sharing and coordinating services between departments. “We had a revolving door of clients getting served, one department at a time, but not really maintaining sustainable solutions,” says Carolyn Staats, Director of Innovation for Sonoma County Central IT. “We continued to have high rates of homelessness, and we needed to do something.”

After learning about how another large California county used IBM solutions to improve safety net services, Sonoma County managers also began consulting with IBM. “To collaborate, you need a way of getting data out of all these systems in a format that is very user friendly for the caseworkers.” says Staats. “That’s where IBM came in.”

But then new challenges surfaced in October 2017, when the Tubbs wildfire raced through Sonoma County. It burned 36,000 acres, destroyed thousands of buildings and displaced hundreds of people into shelters set up by the Federal Emergency Management Agency (FEMA). When FEMA shelters began closing two weeks after the fire, many people still had no place to go, and the homelessness crisis worsened.

During this period, the Sonoma County Board of Supervisors launched a new program called Accessing Coordinated Care and Empowering Self-Sufficiency (ACCESS) Sonoma County. The goal was to help the community’s most vulnerable citizens receive the assistance they needed and become more self-reliant. But to achieve this goal, ACCESS Sonoma needed to accelerate IMDT deployment and provide team members with the tools and technology to make an impact.

“The issue is not as much a dearth of resources. There is an abundance of resources,” says Gore. “The issue was integration and the ability of our teams to use ACCESS Sonoma with IBM — to surgically go after the problems of the community. It’s given us a huge amount of momentum.”

To tap into the experience and knowledge of ACCESS Sonoma IMDT members, Sonoma County and IBM Consulting™ conducted an intensive IBM Garage® planning workshop. “We had caseworkers and program managers doing Design Thinking and it was really amazing,” says Staats. “They worked through different scenarios and the personas in those processes. Having everyone at the table and talking about clients from different perspectives was instrumental. IBM made that happen at a very critical time.”

Soon after the workshop was completed, Sonoma County moved quickly to develop an ACCESS Sonoma plan that would benefit the whole organization. IBM was tasked with designing an integrated technology solution to transform business processes, break down silos, share data between departments and coordinate support between agency providers and clients.

In the aftermath of the Tubbs fire and with the pressing need to address the homelessness crisis, time was of the essence. IBM started configuring the ACCESS Sonoma platform in the spring of 2018. “Because IBM designed this open architecture that literally could be lifted and shifted, we loaded 91,000 clients and linked them across four key systems in four months,” says Staats. “That’s an amazing timeline.”

Like most other government entities, Sonoma County already licensed preexisting software solutions from multiple vendors. “We wanted to have the benefits of those investments without duplicating them in other technology solutions,” says Staats. “IBM listened and built a platform with the right architecture, based on our requirements.”

IBM developed a customized hybrid cloud solution with components deployed on premises and on IBM Cloud®. The system also managed an existing workflow management solution on a third-party cloud platform. IBM Health and Human Services Connect360 operates as a data integration hub and works with IBM® InfoSphere® Master Data Management (MDM) software, bringing data together from siloed source systems to form a master client index. MDM creates a single, integrated record for each client that can be updated in real time, giving users a 360-degree, holistic view of each client.

IBM Watson® Care Manager, supported on IBM Cloud, provides a window for IMDT users to see aggregated data about each client, enabling integrated case management. The tool also surfaces insights from case notes to develop action plans for each client.

The ACCESS Sonoma solution and data storage are migrating from on-premises servers to the Microsoft Azure cloud environment, with managed services and support enabled by Red Hat® Open Source® software.

Since the initial deployment of ACCESS Sonoma, IBM has delivered five phases of additional use cases and system features. These include new client cohorts, data sources, reports, analytics and additional API integrations.

ACCESS Sonoma continues to integrate data across agency systems and give frontline workers real-time, holistic views of client needs. “It’s very user friendly for non-technical people. You can quickly get the information you’re looking for, whether a dashboard or individual client information,” says Staats. “The solution works and it doesn’t break.”

After launching ACCESS Sonoma with IBM, Sonoma County began to see more people brought out of homelessness caused by the pandemic, natural disasters, economic disparities, the high cost of living, addiction, recidivism and untreated mental health issues. At the same time, Sonoma County was able to deploy resources more efficiently to help more people.

In 2019, a wildfire burned encampments and homeless people congregated on a hiking trail near Sebastopol. The Joe Rodota Trail became the largest and most visible homeless encampment in Sonoma County’s history. ACCESS Sonoma enabled the County to address the crisis immediately, which was a huge and visible validation of its effectiveness. Many unhoused people were provided access to services for improving health and well-being and accelerating reintroduction into the community.

From 2018 to 2019, the homeless population count in Sonoma County declined by 2%, and declined another 7% from 2019 to 2020, resulting in a combined two-year decline of 9%. Sonoma County also achieved a 35% housing placement rate for unhoused clients, a rate over four times higher than the US national average. “We have opened up numerous permanent supportive or transitional housing sites,” says Gore. “And holding this together is the ACCESS Sonoma program that we’ve worked on with IBM.”

Many homeless people in Sonoma County have been diagnosed with mental illness, and a portion of these people have been incarcerated after committing non-violent crimes. Typically, these individuals are released from jail early to receive mental health care, with the goal of making it less likely they will be repeat offenders.

The national average for recidivism in the mental health cohort is 76% and Sonoma County experienced similar results before enrolling clients in ACCESS Sonoma. “In the mental health cohort, we have seen recidivism fall to 13%,” says Staats. “We have an 85% success rate with mental health diversion through ACCESS Sonoma because of the wraparound services we provide our clients.”

Another recurring challenge is when homeless people seek treatment for non-emergency conditions at a local hospital Emergency Department (ED). This option incurs high costs for the county government. To provide homeless patients with more appropriate and holistic treatments through community clinics and other services, the local hospital enrolled them into ACCESS Sonoma. As a result, the ED recorded 32% in cost savings due to fewer admissions from homeless patients.

After the COVID-19 pandemic struck Sonoma County in 2020, the flexibility of ACCESS Sonoma technology platform was put to another test. The County needed a COVID-19 symptom checking application as soon as possible to help employees determine if they were infected or should seek medical care. “IBM let us know that they already had a public health platform working for another state that we should look at,” says Staats. “We started working together immediately and had our first app available on the Apple Store in one month.”

“Our ability to use technology and innovation is helping us track progress against homelessness,” says Gore. “The future is brighter because our investments are going to a place where we can show it is working. That’s the way to achieve sustained progress.”

Other government entities in Sonoma County see ACCESS Sonoma as a model that could work for them. “The local police are looking at this to collaborate with other community-based organizations,” says Staats. “For example, if an individual might be acting out from a mental health disorder, they would be better served by a community provider rather than being arrested.”

Sonoma County is also interested in sharing what it has learned with other governments in California and across the US. “If we build something, we want another county to use it,” says Staats. “Orange County in California is running our solution, and now Harris County, Texas, the third largest county in the US, is going to be running the solution.”

ACCESS Sonoma has received national recognition for its groundbreaking efforts. During 2019 and 2020, the initiative won the Financial Times Intelligent Business Award and the National Association of Counties Achievement Award.

Making a difference in the lives of individuals and families struggling with homelessness has always been the goal of Sonoma County’s social service professionals, and now they have effective tools, which they helped design with IBM. “We always thought it was going to be the human touch and didn’t take into account how technology could be instrumental in helping to change things,” says Rivera. “But bring touch and technology together and starting to see how we could move the needle has been amazing.”

After living precariously for over a year with her son in a car, Patricia became part of the ACCESS Sonoma initiative. “The care team enrolled her in various safety net services and encouraged her when she struggled. She began attending therapy sessions regularly and her son was successful in school,” says Rivera. “She was connected to stable housing and today, she is on her way to self-sufficiency — for the first time in her life.”

World renowned for its wine industry and natural beauty, Sonoma County is located north of San Francisco and covers 1,575 square miles, with a population of almost 500,000 residents. The Sonoma County government operates 50 departments and agencies and is based in the county seat of Santa Rosa. The County employs over 4,800 people and has annual expenditures of USD 2.27 billion.