coordinated access system homeless data warehouse care

Care CoordinationHomeless Data Warehouse Coordinated Access System

[email protected] | 802.257.0641

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Topic Page

Overview 3

Care Coordination Portal (Social Determinants of Health) 4

Provider Portal (for Social Service Agencies) 8

Client Records 13

Security and User Management 10

Coordinated Access to Housing 12

Rules and Services 13

Cohort Lists 14

Housing Opportunity Matches 15

Housing Performance 16

Green River Company Information 17

Open Path Care Coordination, Data Warehouse, and Coordinated Access


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Overview

Open Path serves as an analytic data warehouse to supplement existing HMIS reporting; an integration platform for merging HMIS records with other data sources, such as medical information; a tool for providers to actively coordinate care and manage service prioritization; and provides a sophisticated set of functions to handle coordinated entry decisions and related communications for housing opportunities.

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Key platform components and data flows.

EHR

HMISService Agency

Access

Medicaid Eligibility

HMIS

HMIS

EHR

Medical Provider Access

Anonymized Data Reporting

Coordinated Access to Housing

Care Coordination

Medicaid Claims


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L Medical Records and Collaborative Care Planning

Along with collecting HMIS data, the warehouse is also set up to consume medical records and Medicaid claim information. Specific client medications, appointments, and medical problems are displayed to case managers (where access is granted). There are tools for integrated care teams to manage goals and outcomes related to social determinants of health.

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Integrated care planning screenshots, showing data collected from multiple agencies’ EHR and Medicaid claims data. Currently used by Boston Health Care for the Homeless.


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L Medical Records and Collaborative Care Planning (Continued)

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Charts on client records showing housing status and assessment results over time.


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Reporting from Medicaid claims data, for individuals and across the project.


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Arizona Self-Sufficiency Matrix and InterRAI Community Health Assessment forms can be completed directly in the platform.


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Client Records

Since inception, the system has been designed not only to support reporting and analysis, but to provide comprehensive data on individual clients - for program administrators, case managers, working groups - to both help coordinate services, and support fair, data-driven prioritization processes.

A user (with the appropriate permission set) can view a single client record combining information from all available data sets.

There are also options to limit what data is visible to specific users (and user groups), which include view restrictions based on data source (e.g. exclude data from a specific HMIS), project, type of data (e.g. hide SSNs), and status of client consent. Access can be restricted to the point where, say, only names and assigned case managers are visible.

Individual client “dashboard.” Client photos can either be pulled via API, or uploaded separately into the warehouse.


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Client Records (Continued)

Screenshot of the calendar view of a client’s combined HMIS service record (above), and functionality for attaching files directly to warehouse records (below).


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L Security and User Management

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The warehouse has the security controls necessary to house and manage highly confidential Personal Identifiable Information (PII) and Personal Health Information (PHI). Technical measures include maintaining client data encrypted "at rest"; enforcing connection protocols so client data is encrypted "in transit" (between application server and database instance, and between application server and web browser); routines that automatically log out inactive users; and audit logs of user activity.

Individual user access can be managed in several ways. The platform is designed to support roles ranging from administrators with unrestricted access, to users who can see nothing but a specific report. Roles can also be defined to limit a user's access to parts and functions of the system, as well as to parts of a client's record (e.g. restricting demographic data or residential enrollment history).

Screenshots of user account and role management.


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Access can also be limited by data source: if a data sharing agreement prohibits access to specific HMIS records (other than for aggregate reporting), for example, that information can be hidden in user interfaces that present other HMIS records. Access can also be limited by specific HMIS project, and if the platform is used to handle "by name" cohort lists, restrictions can be applied to those lists individually as well.

Options for limiting a user’s access by data source or project (above), and to specific reports (right).


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ESS Coordinated Access Overview

In addition to the warehouse functionality described above, there is a separate section of the open source platform for managing coordinated access to housing. Housing opportunities (units, vouchers) are listed within the system, tied to programs and funding sources that have eligibility requirements, along with the services offered. When a vacancy arises, the system prioritizes available homeless clients (using data from the warehouse). Rules for prioritization are based on community preferences, and might include criteria such as first day homeless, total days homeless in the last three years, a vulnerability assessment score, et cetera.

Once a "match" between vacancy and client is made, the system manages a set of communications and action steps - notifications, requests for approval or additional information - between a set of actors (housing navigators, case managers, the clients themselves) through move-in.

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People in Need of Housing

Housing/UnitsAvailable

CAS

Match Suggestion

Communications to involved parties: notify and request action

Move in!

Housing inventory, current vacancies, and homeless individual data can be managed from within the CAS or can come from the warehouse.

A core function of the CAS is to generate ideal matches between individuals and housing opportunities, based on customizable eligibility criteria and prioritization logic.

Email notification go to interested parties regarding a proposed match. These can be strictly informational, or require action that rejects or moves ahead a match.


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ESS Rules and Services

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Eligibility rules and services can be attached to funding sources, programs, and buildings.


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Clients can be tracked on “by name” cohort lists, and prioritized for housing opportunities based on algorithms specific to a community.


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Coordinated Access matches in progress, details on a particular client match step, and example site configuration options.


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Coordinated Access performance reports.


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Green River

Year incorporated: 2000

Employees: 20. Includes core team members who focus on back-end development, front-end development, data management, DevOps, UX design, visual design, and project management.

Location: Primary offices in Brattleboro, VT, with remote staff in New York, Chicago, Cedar Rapids, and Seattle.

Core services:● IT Needs Assessment and Strategy Consulting● System Architecture Evaluation and Creation● Database Design and Management● User Research● Software Design and Development● Visual Data Analysis

Green River is a web application development and data analytics firm founded in 2000. We are actively working with the City of Boston, City of Springfield, MA, Boston Health Care for the Homeless Program, Massachusetts Department of Housing and Community Development, Community Action Partners Pioneer Valley, Homeward Virginia, and Tarrant County Homeless Coalition on the homeless data warehouse and coordinated access to housing system illustrated above.

We believe strongly in doing work that affects positive change in the world. Our other projects include building a Health Equity Portal for the Connecticut Association of Directors, and working with the Connecticut Health Department on an innovative methodology for the topographic visualization of environmental and public health data. The goal is to communicate complex statistical phenomena to the public—simply, effectively, and compellingly. We are working with the State of Delaware on a novel, neighborhood-focused environmental public health initiative to present usable data to both the public and specialized researchers. And, more globally, for the past 10 years we have been building the data collection and analysis platform behind Starbucks’ C.A.F.E. Practices supply chain certification, which covers workers and communities in 29 countries and now includes cocoa and manufactured goods. We have also designed dashboards, visualizations, and interactive applications for organizations including B Lab, Verité, Scholastic Corporation, Education Resource Strategies, GRESB, and the National Education Association.


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Michael Knapp, Ph.D. is CEO and a founding Partner at Green River. Michael is a data analyst who specializes in web-based application development. Michael has managed the development of dozens of web-based applications during the past 11 years at Green River. He was trained as an applied bio-statistician, conducting health analyses with SAS software and working with spatial data. His interest in Web-based instruction arose from the graduate level courses he taught in Internet research, Web application development, and Intranets in the late 1990s. Michael has a PhD in Public Health from Yale University, and a Masters in Environmental Management from the Yale School of Forestry and Environmental Studies.

Julie Strothman is User Experience Director at Green River. Prior to her work at Green River, Julie managed user research at Landmark College, a two-year college for students with learning disabilities and attention disorders. At Landmark, her work included NSF-funded projects to broaden participation in computing among under-represented groups. Julie’s current challenges include ensuring agile processes truly include real user feedback in each design iteration. Julie conducts user research, usability testing and website analytics to improve design, and to ensure accessibility in our software. Julie has an M.S. in Internet Strategy Management from Marlboro College Graduate School.

Derrish Repchick is COO and a Partner at Green River who has well over 20 years’ experience designing, developing, and deploying large-scale software applications. Before joining Green River in 2011, Derrish was the co-founder of Intellidimension, developer of a high-performance database platform. Prior to that, Derrish gained his expertise as a technology consultant for the financial services industry as a software architect for Tally Systems Corp., and an information technology professional for United Technologies. Derrish has a B.S. in Electrical Engineering from the University of Massachusetts and an M.S. in Computer Science from Rensselaer Polytechnic Institute.

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Ian Kozak is Director of Strategic Development and Product Manager for Open Path, Green River's platform for social services data integration. Ian works closely with organizations and communities to craft and utilize optimal technology solutions to support their innovation, and has presented on the process and results at numerous conferences nationwide. Prior to joining Green River, Ian led the IT department at Marlboro College, and was the founding partner in two educational software development companies. He has a B.A. in Anthropology and Biology.

CEP Online Reporting System - User Experience Improvements • Green River • (802) 257-0641 • [email protected]

coordinated access system homeless data warehouse care

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