New technology solutions do not necessarily fix old problems. Conversely, not every technology platform keeps up with the operational needs of organizations when policies or programs change. As communities and participants in CalAIM begin to confront the realities of providing, managing, and coordinating Enhanced Case Management (ECM) and Community Supports services they are increasingly asking themselves (and their community partners) questions like:

• • Is there a more efficient process (for things like generating claims for non-medical services, or consolidating SDOH information for reporting purposes)?
  • Can we get data from other organizations on common clients (especially important for broad coordination services for complex patients by ECM providers)?
  • Do we need a new technology solution, do we need multiple solutions?
  • How do we pick the solution that is right for us?
  • How do we pick a scalable, sustainable solution that isn’t just going to take us to next year or solve a single problem?

Large organizations, such as health plans, hospitals, or community clinics, may have dedicated IT teams or project managers available to discover requirements and manage process change. However, many organizations that provide health and social services are resourced challenged and are burdened with frequent staff turnover and IT resources that may be more attuned to solving clinical workflow problems rather than considering broad community-wide strategic data sharing circumstances; making it difficult to identify organizational needs and manage change internally, let alone in the context of a community-wide CalAIM service delivery system.

Understanding this resource gap, the Department of Health Care Services (DHCS) launched the Providing Access and Transforming Health (PATH) Technical Assistance (TA) Marketplace. This hub serves a critical role in CalAIM, providing the ability to navigate and connect CBOs and other CalAIM stakeholders to subject matter experts that can supplement their team and identify sustainable technology solutions–whether a simple integration or the procurement of an ecosystem of solutions.

Intrepid Ascent’s Technology Strategy Group has engineered several solutions that can be delivered in a traditional consulting model or purchased as an ‘off the shelf’ solution, where the organization completes online assessments, and a series of products are customized for the organization to review and submit to vendors.

Our process leverages a vast data lake of user interviews, procurements, and client implementations. In our Technology Gap Assessment, users at every level of the organization can access our on-demand technology tools and answer questions suited for their level of technology familiarity. The conditional based tool allows users to answer questions which then are translated into technical needs. These needs are compared to other organizational respondents to identify likely gaps.

Once a report has been generated, an organization may choose to pursue some of the provided recommendations. These recommendations could be around existing workflow changes, but more likely an integration or procurement.

Intrepid’s Technology Strategy Group has developed follow on technology tools for integrations and procurements meant to be used as a subsequent process following a gap assessment or for organizations that have already identified a need for one of the two products:

Technology Integration Discovery and Specifications Development: Integrations can be particularly challenging because they are usually done between different vendors and require an ability to translate data needs into a common data format used between the two organizations. Furthermore, a very common scenario under CalAIM is the need for integration between a HIPAA covered entity and a non-HIPAA covered Community Based Organization (CBO), which could involve a very secure, complex EHR establishing an exchange with a nonclinical coordination platform or a community repository of information critical to providing core CalAIM services – like a local Housing Information Management System (HMIS). Intrepid has developed an online tool that enables users to identify their business cases and receive an output of technical specifications for vendor guidance.

Technology Procurement: Procurements for new technology solutions, especially when a given technology sector is still emerging, are always tricky; often relying on staff with limited experience in procurements to make decisions that ultimately lock the organization into a solution for years. Furthermore, the question is always asked, “What solutions are out there?” Even with the Internet at our fingertips, it can be hard to find technology solutions that are the right fit for your business operations. Intrepid Ascent has developed an online procurement tool intended to be used through a facilitated procurement management process allowing for everything to happen in our cloud-based portal solution. If an organization doesn’t already have a vendor in mind, Intrepid Ascent can help identify potential vendors and then send a link to these vendor candidates. Vendors will upload documents, answer, and ask questions all in the online portal. Upon vendor proposal submissions, evaluators receive summary reports where they can rank and score the different vendor candidates entirely online. The culmination of this guided procurement process is a decision meeting where evaluators can look at anonymized voting patterns of scoring categories by other members along with analytical breakdowns of vendor product maturity and desired feature availability.

The process is remarkably simple, enabling busy executive teams and/or broad community coalitions to make informed decisions quickly, but it also streamlines the process for vendors – standardizing their responses and making for an easier side-by-side evaluation.

We are excited to be part of the CalAIM PATH TA Marketplace and looking forward to meeting your team and identifying the best solutions for you!

To learn more please visit our TA Marketplace Page on our website or browse our 27 off the shelf project offerings on the TA Marketplace.

The California Advancing Innovation in Medi-Cal (CalAIM) initiative represents one of the most ambitious efforts to overhaul a state’s Medicaid program in recent memory. Just over one year into the five-year rollout, stakeholders are gearing up for the next round of implementation milestones in 2023 and beyond. This summer, one of CalAIM’s core service delivery improvements, Enhanced Care Management (ECM), will go live for new, at-risk populations (e.g., children and youth). County jails and youth correctional facilities will begin building the health technology infrastructure to deliver first-of-its-kind health and social services to individuals reentering the community. And many counties participating in CalAIM’s behavioral health initiative, the Behavioral Health Quality Improvement Program (BHQIP), will implement new electronic health record (EHR) platforms or leverage new integrations with their regional health information exchanges (HIE).

The success of these CalAIM initiatives is dependent upon robust and secure data exchange among stakeholders. Early lessons from CalAIM implementation through California’s managed care plans (MCPs) consistently demonstrated that local providers and community-based organizations (CBOs) lacked the technical and operational support to facilitate meaningful connections to critical health and social service information for CalAIM.[1]^,[2] In addition, stakeholders face a complex web of new and oftentimes conflicting state and federal regulations governing the exchange of health information and other types of sensitive data (e.g., social needs, behavioral health).

New state laws like Assembly Bill 133 (AB 133) sought to provide a safe harbor from existing California regulations for CalAIM stakeholders[3] by permitting broad exchange of health and social service records. However, AB 133 does not preempt more stringent federal rules governing the exchange of substance use disorder (SUD)[4] or Homeless Management Information System (HMIS),[5] two types of data that are crucial to painting a picture of the “whole person” within Medi-Cal’s enormous delivery system.

 Given the scope and complexity of CalAIM’s data sharing objectives, stakeholders have a growing to-do list before data is ever exchanged. There are regulations to interpret. Policies and procedures to amend. Agreements to review and revise, then review again. Readiness assessments of existing data systems and organizational practices. The list goes on.

 We learned from our early CalAIM implementation work with MCPs and community stakeholders that the available guidance from the state isn’t enough, despite the best of intentions. Many organizations may opt to err on the side of caution when it comes to data exchange, undermining the foundational goal of CalAIM: leverage cross-sector data sharing to upend the status quo for vulnerable, at-risk Californians. It’s no surprise that stakeholders need certainty as they wade into a still-evolving landscape for cross-sector data sharing.

 In February 2023, the Department of Health Care Services (DHCS) launched the Providing Access and Transforming Health (PATH) technical assistance (TA) marketplace to connect CalAIM stakeholders – CBOs, providers, county agencies – with experts who can provide critical support with implementation of ECM and community supports. Intrepid Ascent’s Policy Innovation Group (PIG) has developed 9 unique products and services for the TA marketplace specifically designed to meet the needs of CalAIM stakeholders as they establish a new data governance framework for CalAIM.

Our team of policy consultants crafted these products and services based on industry-leading experience in information privacy and data governance from real-world clients, including our recent work with Whole Person Care (WPC) and CalAIM clients. Each product or service ensures that your organization has a plan for meeting statewide data sharing requirements, while aligning with the fundamental vision for a more data-driven, whole-person centered Medicaid delivery system in California.

To learn more, visit our website or find us on the PATH TA Marketplace.

[1] HealthNet. https://www.healthnet.com/content/dam/centene/healthnet/pdfs/general/ca/hn-calaim-lessons-learned-recommendations.pdf

[2] CHCF. https://www.chcf.org/wp-content/uploads/2022/05/LaunchingCalAIM10ObservationsECMCommunitySupports.pdf

[3] See Civ. Code § 56 et seq (Confidentiality of Medical Information Act), WIC § 5000 et seq (Lanterman–Petris–Short Act), WIC § 10850.7

[4] 42 CFR Part 2. https://www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2

[5] 24 CFR § 578.57. https://www.law.cornell.edu/cfr/text/24/578.57

Technology is only as good as how it is used.

This statement is simple, yet the process behind the use of these systems is complicated. How many of us have had a negative experience adopting new technology? How many of us have tried, and failed, to roll out a new platform within our organization? Yet technology continues to be at the center of cross-sector collaboration initiatives – such as California Advancing and Innovating Medi-Cal (CalAIM) and its predecessor Whole Person Care – and the California Data Exchange Framework (DxF) will only expand on that.

We have spent the past five years guiding more than 2,000 users through onboarding to various technology platforms, and through this, we have learned what works and what doesn’t when it comes to supporting the people-side of technology implementation and adoption. During this time, we have defined and refined Best Practices for Technology Onboarding. These concepts are baked into our onboarding approach and help to shape and define what we do.

Here are our top 3 best practices:

1. Manage Change. It’s a fact that change is a daily occurrence in our lives. We believe how we prepare and react to change strongly influences the overall outcome of a project. Our approach to change management highlights two critical points: change causes a variety of positive and negative emotional reactions, and how people respond to change matters. Our understanding of how people respond to change is what drives our approach to onboarding. We purposely segment onboarding into distinct phases to allow people to react to and understand change as the process flows

2. Identify and involve key parties in stakeholder engagement. Mapping stakeholders at all levels of the project aims to ensure all voices are represented appropriately, including quieter voices or those that historically have not been invited to the table. To do this we utilize the networks of stakeholders that already exist and ask them a series of questions, including:

– Who else is missing from the project?
– Who are the champions or key leaders that will be advocating for this project or helping to remove barriers along the way?
– Who are the people that will help implement this project, the “doers and drivers”?
– Who are the people who will be using the product, the “customers”?

We use these guiding questions to help think outside of the box to try and capture all parties that have a hand in the process. From there, we encourage visually mapping the stakeholders to understand what the connections are and how they can support each other and the implementation of the technology solution.

3. Define success for your project and monitor over time. When thinking about technology onboarding, defining success allows you to identify whether your onboarding approach is working the way you intended. For instance, your end goal might be for someone to use your system for referral purposes, but instead, you observe that users are logging in to look up demographic information. You can target additional support towards getting people to understand how to send referrals, rather than spending time supporting people logging in. It’s important to define success early so you know what you and your team should be working towards, and so you can celebrate wins as they come!

Through our work, we have refined an approach that leverages best practices for technology adoption and created a Technology Adoption Toolkit to support users at any step in the onboarding process.  The Toolkit is accompanied by a corresponding workbook for learners to practice skills, apply knowledge to personal scenarios, and help prepare for real-world application. This model follows a learn-as-you-go approach to support various learners and the individual experiences they bring to their learning journey. Our content guides those designing technology onboarding plans through the entire technology onboarding process.

Our innovative Toolkit presents tips and techniques for understanding organizational readiness for technology adoption, analyzing and revising workflows to support implementation of the new solution, and suggesting opportunities to implement continuous feedback loops and small tests of change (or PDSA cycles) throughout the process.  The Toolkit also explores different training approaches, strategies for developing engaging training content, and tips to support adoption after training.

We know implementing a technology solution is only part of the picture – getting people to use it is the hard part. Let us help you along your journey!

To view our toolkit, or more about our TA Marketplace offerings, please visit our website.

If you have seen the news that DHCS’ CalAIM PATH Technical Assistance (TA) Marketplace is live but thought you missed an opportunity, you’re in luck – it’s not too late to register and receive support with your CalAIM needs. 

PATH, which stands for Providing Access and Transforming Health, is a five-year, $1.85 billion initiative to build up the capacity and infrastructure of on-the-ground partners to successfully participate in the Medi-Cal delivery system as the state widely implements Enhanced Care Management (ECM) and Community Supports and Justice Involved services under CalAIM. The TA Marketplace is a critical component of PATH, providing funding for providers, community-based organizations, counties, and other entities to obtain technical assistance resources needed to implement ECM and Community Supports. It is a virtual marketplace for services that include both hands-on, custom support, and off-the-shelf products ready for implementation.  

How do you know if you are eligible to receive services? First, you must be an eligible recipient type, such as: 

• City, county, and other government agencies 
• Public hospitals 
• Provider organizations (health and/or behavioral health) 
• Community-Based Organizations (CBOs) 
• Justice Agencies 
• Medi-Cal Tribal Designees and Indian Health Programs 
• Others, as approved by DHCS 

Second, TA recipients must be actively contracted with Managed Care Plans (MCPs) for ECM / Community Supports. If your organization is one of the approved eligible recipient types but is not yet contracted with an MCP for ECM/Community Support, you can still apply as a TA recipient if you provide a signed attestation that you intend to contract to provide ECM / Community Supports. Alternatively, entities that are not contracted or actively engaged with a MCP may seek DHCS approval to register as a TA Recipient by sending an email to ta-marketplace@ca-path.com to request such approval.   

To shop services on the Marketplace, eligible entities must submit a TA Recipient Registration Form on the DHCS TA Marketplace website. Applicants must provide evidence of a contract(s) with managed care plans (MCPs) that provide Enhanced Care Management and/or Community Supports, intent to contract with MCPs to provide Enhanced Care Management and/or Community Supports, or approval from DHCS to register as a TA recipient. 

Once accepted, TA recipients will be able to shop for off-the-shelf TA projects or request hands-on, custom support. “Off-the-shelf” TA projects have clear, pre-established goals and defined timeframes for easy consideration. Intrepid Ascent has 27 approved off-the-shelf projects across the following Domains: 

• Domain 1: Building Data Capacity: Data Collection, Management, Sharing, and Use 
• Domain 3: Engaging in CalAIM Through Medi-Cal Managed Care 
• Domain 4: Enhanced Care Management (ECM): Strengthening Care for ECM ‘Population of Focus’ 

Eligible entities may also request hands-on, custom TA services to design and implement systems, training, and recruitment processes uniquely suited to their priorities and needs. TA goals, deliverables, and timeframes are all developed “from scratch” and are specific to the individual entity and project. 

Intrepid Ascent is an approved vendor for the PATH TA Marketplace to deliver DHCS-approved services and resources to eligible organizations at no cost to them, with DHCS directly funding our work.  You can find additional information on our expertise and the services we provide by visiting our website. To learn more, please contact calaim-ta@intrepidascent.com to set up a meeting with our team to walk you through our offerings on the Marketplace and learn how we might be able to support the needs of your organization through DHCS-funded TA.  

The seeds were planted over the past several years, some into well-plowed rows, others more optimistically tossed on seemingly fertile ground, all across the state. And now (after all this rain!) the green shoots of CalAIM have flowered like California poppies in the spring. This is not a pilot project, this is an entire landscape changing at scale. With innovations unfolding all around us, we are witnessing and we are participating in the rapid evolution of the Medi-Cal delivery ecosystem.  

The advances are many, as we move toward locally integrated service environments to support whole person care for Medi-Cal beneficiaries. With Enhanced Care Management (ECM), the personalized coordination of services across organizations and sectors represents the greatest single effort, ever, to link health care services with Community Supports (CS) addressing Social Determinants of Health. Population Health Management, launched in January, builds upon these new approaches to encompass the entire Medi-Cal beneficiary population, roughly one out of three Californians. The impact, on both individual lives and persistent social inequities, promises to be profound and is significant grounds for optimism. 

We are deeply involved in this transformation at Intrepid Ascent. Years of work with multiple Whole Person Care pilots opened our eyes to the challenges and opportunities of broad, technology-assisted coordination among care teams from health care, housing, and allied sectors. With the pivot to CalAIM’s ECM and CS, we’ve supported communities in the adoption of new technologies, policies, and workflows, and we are facilitating collaborative planning in Contra Costa and San Diego Counties for DHCS. Now, broadening to the scale of Medi-Cal, we were recently selected to offer services through the PATH TA Marketplace across the state. With 27 pre-designed Off-the-Shelf offerings in the Building Data Capacity domain (and two others), and with the flexibility to create Hands-On TA services, we’re ready to support organizations and their stakeholders as they cultivate new solutions at this moment. Please visit the TA Marketplace page on our website for additional information on Intrepid Ascent’s expertise and how we might be able to support your organization through the TA marketplace.

Dear Colleagues,

As 2022 draws to a close, both the season and the sequence of events in our field make this a time of deep reflection, anticipation, and hope. The waves of the COVID-19 pandemic have diminished in force and regularity. Hospitals, clinics, and public health departments have begun to emerge from crisis mode to survey the wreckage, to appreciate institutions that held the line, and to consider opportunities to rebuild in new ways. The disparities spotlighted by the pandemic are adding policy-making momentum to integrate health care with allied fields, such as social services and housing, to address the social determinants of health and structural racism. Billions of dollars will flow into the Medicaid delivery system alone linked to related models and initiatives.

Just as importantly, we’ve begun to come together in person again to advance this work. Last week I attended the annual conference of the California Association of Public Hospitals / Safety Net Institute (CAPH/SNI) with several hundred companions. The positive in-person vibes and feedback loops flowed from the podium to the dance floor, which was hopping. And the commitment in the room to a robust public health care infrastructure was infectious and inspiring: check out these videos on award-winning health systems for advancing high quality equitable care in 2022. Several of these efforts incorporate technology tools in new and promising ways, such as linking clinic patients with healthy food delivery (Santa Clara County) and proactively engaging populations to improve health outcomes (Contra Costa County). At Intrepid, we are delighted to be supporting the overall award-winner – Alameda Health System’s BElovedBIRTH Black Centering – to onboard to a public health case management system.

Intrepid took several steps in 2022 that broadened our horizons and positioned us to journey further with our clients in 2023:

• Early this year we created three consulting groups – Technology Strategy, Policy Innovation, and Community Change – and have continued to hire talented, passionate people to our team  
• We published a series of “Data Exchange Explainers” with the California Health Care Foundation to inform policy-making for the state’s Data Exchange Framework, honing our abilities to translate complex topics to broader audiences
• We supported multiple communities in the adoption of technology for collaboration across sectors, from planning to implementation to training and workflow redesign, increasingly in the context of CalAIM goals to transform the Medi-Cal delivery system
• We expanded our work with public health as it emerges from the pandemic, beginning with the case management system in Alameda County mentioned above, but also with other public health departments building data integrations with health care delivery partners; and we facilitated a multi-region initiative on approaches to addressing congenital syphilis
• We also broadened our work in the behavioral health arena, assisting multiple behavioral health entities to advance their technology and policy infrastructure for data sharing
• We actively monitored New York’s proposed 1115 Medicaid Waiver program, engaging in conversations with colleagues throughout the state, as we adapt our services for California’s 1115 Whole Person Care Program and CalAIM initiative to the emerging New York environment; and
• We prepared new ways for clients to access our expertise, with significant investment in developing toolkits, off-the-shelf resources, and technology-assisted services that will become available in 2023.

We are grateful for the opportunity to participate with you in this transformative moment and look forward to joining forces next year. In the meantime, I hope that all of you are able to slow down, to settle into the changing season, to reflect, and to gather in warmth with family and friends.

See you next year,

-Mark

As California shifts towards cross-sector collaboration under the sails of California Advancing Medi-Cal (CalAIM) there is an increasing need to share data between organizations subject to HIPAA (covered entities) and those that are not (what we refer to as non-covered entities or community-based organizations (CBOs)). For more than 20 years, health care providers have relied on privacy and security frameworks derived from the HIPAA Rules, which provide controls under three primary areas for safeguarding patient data: administrative, technical, and physical. Administrative controls generally encompass the training users would receive and the types of policies that would be implemented to control user access to patient data; technical controls manage the ability to authenticate, authorize, and audit user and system activity against internal misuse and external malicious actors; and physical controls involve the ability to secure patient records and information systems that contain patient data. However, one thing that health care organizations have always needed to manage is what the appropriate balance of these controls is — in other words, where is the greatest risk? 

Currently, most health care data systems are managed via cloud-based software and solutions providers, which generally provide physical and technical security against external threats and distributes some risk away from the organization. Furthermore, organizations can attain additional certifications, such as HITRUST CSF, as required by either health care payors or organizational leadership. Security certifications are generally a third-party evaluation of your security measures according to industry standards and best practices. HITRUST CSF is one of the better-known types of security certifications, but with a particular focus in compliance to HIPAA requirements.

However, this outsourcing of physical and technical security leaves a potential gap: what about data access within a system, or more broadly, within a trusted network, such as a regional or local Health Information Exchange (HIE)? The fact remains that under HIPAA, despite these distributed networks and service providers, it is ultimately the responsibility of a given organization to determine who can access patient data, to what extent, and for what purpose. In health care systems and organizations, the ability to share patient data with other providers within the confines of HIPAA has traditionally been acceptable, as it was assumed the data could is relevant to patient care. This level of access may remove the need for layers of privacy controls for personal health information (PHI); however, what happens if you are a community-based organization, like a homeless shelter or food pantry? This is where a spectrum of philosophies emerge, and the cross-sector data sharing challenge begins.

Most health care privacy and security teams think in two dimensions of patient data: breach and misuse. A breach occurs when patient information is accessible to non-authorized users, whether by a malicious party or when a user with access to the information inadvertently releases it to a third party. These types of events have severe consequences (including fines) for organizations and can potentially threaten patients’ identities depending on the type of information released. On the other hand, misuse occurs when authorized users utilize patient information for unjustified purposes, such as looking up a colleague or celebrity. These types of events can be managed with proper training (administrative) and audit controls (technical). Privacy and security teams generally stop there, but aren’t there other risks, specifically to patient care?

Figure 1, Multidimensional Data Risk Assessment, proposes a different lens that organizations should look through when considering patient data risks. The proportions of the chart are not indicative of any empirical findings, but they could represent a real scenario for any community.  By healthcare organizations deferring to strict access controls, particularly with CBOs, the focus is only on breach of patient data or misuse by CBO staff. However, there are several other risks that could have greater ramifications. What if a referral to an organization only included demographics for a patient contact? How can a CBO really determine eligibility, service needs, and priority without more information? This is a risk which impacts service enablement (i.e., not sharing information with a CBO that is necessary for efficient service enrollment and coordination). An additional risk to consider is patient endangerment, which can occur in several different types of scenarios, such as 1) when people are assigned as roommates in a housing development without considering potential behavioral health issues that may arise between the two, or 2) when medications prescribed by one provider might conflict with those prescribed by another (particularly if the patient did not indicate they were given prescriptions previously). A third major risk category arises in patient experience and the potential for consent fatigue and re-traumatization. For example, should a victim of domestic abuse or child neglect retell their story to several related organizations since they all have strict data privacy policies and do not share relevant information among each other?

Risk is generally the intersection of probability and loss. A breach can certainly be considered a high degree of loss, but often we do not consider the probability of this occurrence. What incentives do malicious parties have with cross-sector information versus web servers that house financial data? Some may offer that identity theft may be the objective, but these systems that contain safety net populations have data which fluctuates constantly, particularly addresses, making it a poor choice for someone trying to establish a fraudulent credit line or bank account. Furthermore, before electronic records, organizations had to trust employees were handling client paper records appropriately and with integrity. How did the onset of technical safeguards diminish this trust? Lastly, reflecting on Figure 1 and cross-sector collaboration involving both HIPAA-covered entities and CBOs, what has the greatest probability of occurring any day of the week:

1. A hacker will breach a CBO system.
2. A staff member will look up a client that is also a neighbor.
3. A patient/client will have to fill out several intake forms with the same information between referring organizations due to strict privacy controls, delaying services while eligibility is confirmed.  

 Critics will continue to cite consent issues and staff misuse/mishandling of information (all valid concerns), along with unique organizational problems as a primary concern above some of the others I’ve mentioned. However, these problems often all resolve to the basic fact that a given organization tends to be most concerned about its own liability versus its patients’ needs. For CalAIM to be successful, we need an effective cross-sector data sharing model that puts patients/clients at the center and effectively mitigates their risks, otherwise, while there may be “no wrong door,” there certainly will be several an individual needs to walk through before receiving services. 

Community Information Exchange (CIE)ⁱ networks develop shared governance and technology to support cross-sector collaboration addressing social determinants of health. They bring together diverse partners from health and behavioral health care, social services, education, the legal system, tribal entities, and other organizations to build relationships, goals, and agreements. By delivering core infrastructure and methods for active planning and collaboration across organizations and programs, CIEs serve as critical hubs in communities integrating systems of care to improve services and outcomes, especially for their most vulnerable residents. 

Many related initiatives have advanced integration within systems of care. For example, Health Information Exchange (HIE) efforts aggregate medical data in one record that clinicians across health systems can access, while housing Continuums of Care have come together to build coordinated entry services and shared documentation in homeless management information systems. CIEs, in contrast, knit together these partners through tools and data that span sectors to provide more holistic and actionable views of community needs and the complexity of individuals. My colleague Mark Elson provides more information on the distinctions between HIE and CIE in a companion post. 

There are many types of processes that CIE networks try to improve through shared goals, agreements, and technology. These often include:  

• • Assessments of individuals’ needs 
  • Eligibility and enrollment in appropriate programs and services  
  • Building an individual care record and a holistic care plan 
  • Facilitating referrals for services across organizations and sectors linked to a community resource directory 
  • Communications and workflows among distributed care teams 
  • Individual consent for data sharing and participation in organizing one’s care 
  • Reporting and analytics to illuminate inequities and upstream causes of health and social issues, and to identify gaps in service supply  

Policy Drivers 

Many programs and funding streams across the country are driving cross-sector collaboration. These include Accountable Communities for Health, Medicaid transformation projects, issue-focused funding (such as Adverse Childhood Experiences (ACEs) Aware), and state legislation that all push for collaboration between health care providers and community-based organizations. Each has a slightly different focus, but all are pushing communities to build connections across sectors to improve services, experiences, and outcomes for vulnerable populations. Below we describe a few programs that have allowed innovative communities and CIE pioneers to start building capacity, infrastructure, and sustainable collaborative practices.  

Federal programs: Center for Medicaid Services (CMS) 

Starting in 2015 to advance the triple aim, CMS began funding some states to implement Accountable Communities for Health.  These began as regional public private partnerships that are designed to be conveners, coordinating bodies, and investment hubs to better connect health care delivery systems to community service providers. In 2016, CMS funded additional five-year Accountable Health Community pilots in 28 communities, which focused on connecting eligible residents with community services to address five core health related social needs: housing, food security, utility assistance, transportation problems, and interpersonal violence. Services focus on screening, referral, and navigation, with most screening occurring in hospital settings. The first evaluation report indicated that most communities built upon existing infrastructure and relationships, but that AHC funding allowed for the formalization of processes for screening and referrals, and expanding capacity for navigation services.  California funded 8 regional ACH communities through these State Innovation Model funds. In the years since then, many other California Medicaid innovation projects have continued to drive cross-sector collaboration. 

 In 2016, California matched CMS funding with state general funds and local sources to test new cross-sector collaboration approaches with DHCS’s Whole Person Care pilots. This program funded 25, 5-year pilot programs to develop new wrap-around case management services to better serve clients with complex needs. These funds allowed lead entities,  

to receive support to integrate care for a particularly vulnerable group of Medi-Cal beneficiaries who have been identified as high users of multiple systems and continue to have poor health outcomes. Through collaborative leadership and systematic coordination among public and private entities, WPC Pilot entities will identify target populations, share data between systems, coordinate care real time, and evaluate individual and population progress – all with the goal of providing comprehensive coordinated care for the beneficiary resulting in better health outcomes. 

This program funding continued regional pressure in California to knit together health, behavioral health, and social service systems of care with improved agreements and collaboration processes or tools. Rather than just focusing on referrals from hospitals, many WPC pilots required the development of a shared care plan across organizations providing care within 30 days of enrollment. This pushed many counties towards identifying cross-sector care teams, developing more sophisticated data sharing frameworks, and implementing secure collaboration tools. Some counties built upon assessment and referral infrastructure. Others focused on implementing tools that would allow for more in-depth data sharing for long-term case management and collaboration. 

State Initiatives: 

Two other initiatives continued to push collaboration for specific populations. In 2018 the State passed Senate Bill 1152 (Health and Safety Code § 1262.5) which requires hospitals to have a written plan for coordinating services for patients experiencing homelessness. This bill increased pressures on hospital systems to have an efficient way to refer patients to community-based services and has led many regional efforts to implement directory and referral networks. In 2020 California also announced funding for the Adverse Childhood Experiences (ACEs) Aware initiative. This program provides grant funding to communities across California to build networks and strategies to address Adverse Childhood Experiences and toxic stress. Grants support provider engagement and training, but also building a network for care planning and care implementation, creating new opportunities and new challenges for existing networks and service providers. 

The outcome of many of CMS’s pilot projects is the creation of a new a Medicaid benefit for vulnerable California residents. This year, Whole Person Care pilots are transitioning many services into Medicaid benefits offered by Managed Care Organizations (MCOs) under California Advancing and Innovating Medi-Cal (CalAIM). The program is focusing on building capacity to implement population health management strategies, and offering integrated services to key populations of interest, starting with Medi-Cal members with complex medical needs (Enhanced Care Management) or who are experiencing homelessness or require other community services to support health like medically tailored meals (Community Supports). Future waves of implementation will include better access to behavioral health services and re-entry services for justice involved adults and youth. While important for long-term sustainability of critical case management and community services, transition of the program to MCOs is challenging the systems set up under WPC pilots. 

CIEs as Multi-Purpose Infrastructure 

What all of these examples illustrate is that there are often short-term initiatives that drive innovation; however, each of these efforts has its specific program requirements and target populations. Building a CIE requires stepping back from each individual program’s specific needs, to consider the broader long-term goals of a community. CIE development must start with those broader goals to build a system that centers the experience and rights of community residents, that does not over-burden community-based service providers, and does not continue to build and re-build with every program transition. Braiding together program funding can bring new providers into the network of stakeholders, or could allow the network to serve new groups of residents, but the goals should be to build a resilient, multi-purpose system of care and collaboration that will outlast any one programmatic funding stream. This requires the lead local entities on specific programs to work through a broader community framework, an approach that at times generates resistance from program managers whose jobs require them to deliver on their specific program needs, often on short timelines from state or federal funders.   

One CIE pioneer, the 211/CIE San Diego, has harnessed programmatic funding opportunities over the past two decades to establish and expand their network of service providers, build a community governance framework, and implement multi-purpose technology solutions. CIE San Diego defines CIE as  

“a community-led ecosystem comprised of multidisciplinary network partners using a shared language, a resource database, and integrated technology platforms to deliver enhanced community care planning. A CIE enables communities to have multi-level impacts by shifting away from a reactive approach towards proactive, holistic, person-centered care. At its core, CIE centers the community to support anti-racism and health equity.”  

In a presentation at the California Primary Care Association meeting in 2019 entitled, “Community Information Exchanges (CIE): Changing the Landscape – Coordinating Social Determinants of Health,” they present a timeline that shows how they have harnessed opportunities to grow, test, and iterate their service offerings over time (Slide 9). These have included initiatives like the ONC’s Beacon Community grants that supported HIE expansion after the passage of the HITECH act, partnership and funding from Managed Care Health Plan partners for health navigation services, and California Whole Person Care funding that helped expand structured approaches to assessment, risk ratings, and developing a longitudinal care record in a shared technology platform. They expand upon some of the influences shaping CIE in the opening sections of their CIE Toolkit, which they offer to other communities engaged in this work. 

211/CIE San Diego has produced and shared many practical resources designed to help communities build beyond individual program requirements. 211/CIE San Diego’s CIE toolkit and the Data Equity Framework (Collaboratively developed with Dr. Rhea Boyd and Health Leads) provide tools that center community vision, goals, and control of information and data. They offer both written materials and a series of sessions from the 2021 CIE Summit called “Leading with Community to Drive Systems Change.” In addition to sharing lessons learned on broad CIE implementation they offer many materials to help CIE communities put equity theory into practice through their series on Leveraging CIEs for Equitable and Inclusive Data. This includes the data equity framework, a vision for the future, and examples of CIE work in communities around the country. In 2022, they are focusing their convening efforts on a conference called Aligning California, Maximizing Opportunities to Advance Local Community-Led Networks. The need for this type of convening stems from both the opportunities and challenges communities feel as CalAIM and other pressures push regional networks to adapt to new programmatic demands. 

Conclusion 

CIEs are ideally positioned to power cross-sector collaboration and data sharing to address community needs across programs. Many communities developing CIE services are sharing learnings and tools to build policy and technology frameworks that center on clients, support front-line service providers, build local control of data, and unify systems of care. We will explore how large-scale initiatives such as CalAIM can support broad systems planning and collaboration rather than building new program silos, and how some communities are doing this work, in future posts. 

ⁱ CIE® is a registered trademark of 211 San Diego. For more information about the trademark, see the following webpages on the legal status and brand guidelines for the term.  

Propelled by local and government demand for services coordination across health, behavioral health, housing, and other social services, the concept of Community Information Exchange (CIE)ⁱ is gaining momentum in communities across the country. As explained by my colleague Keira Armstrong here, CIE enables collaboration and data sharing to address social determinants of health through whole person care approaches. 

In this post, I contrast Community Information Exchange (CIE) with Health Information Exchange (HIE) to cast into relief important differences, highlight core similarities, and explore the alignment of HIE and CIE services. A primary goal here is to assist health care colleagues who are familiar with HIE to grasp more concretely the opportunities and challenges of CIE and what they mean for our field. I conclude with considerations for HIOs that wish to expand to offer CIE services and, on the other side of the coin, offer recommendations for CIEs that seek to leverage the value of health information exchange in their communities. 

What’s in a Name? 

It has become standard practice to refer to the act of health information exchange (“the verb”) as HIE (or “data exchange”), while referring to organizations that facilitate and manage HIE as Health Information Organizations (HIOs). In contrast, the term Community Information Exchange (CIE) designates both the act of engaging in CIE and the organizations dedicated to facilitating this activity (CIEs). I will focus here on HIOs and the services they provide rather than on broader national EHR-based networks for data exchange given that CIEs have much more in common with HIOs than with the national networks. 

The name “Community Information Exchange” bears a clear resemblance to “Health Information Exchange,” and “CIE” likely was coined in reference to “HIE.” Whether intentional or not, the name “CIE” gives the impression of describing the same phenomena as HIE, but with a twist: a focus on the community level of exchange and the inclusion of non-clinical data from social and human services. However, as we will see, CIE generally does not simply take the form of HIE and sprinkle in some additional data elements; while they do share important characteristics, there are fundamental differences in orientation, services, and aims. In short, while HIOs facilitate data exchange among health care providers and health plans for a complete historical clinical record, aspects of which can be delivered into clinical workflows, CIEs serve as user-facing collaboration hubs for coordination of services across sectors.   

Many programs, for instance Medicaid delivery system integration efforts such as the 1115 Waivers in California (CalAIM) and New York (DSRIP 2.0), require significant CIE services but do not use the term “CIE” to denote them – reflecting the fact that we are dealing with emerging phenomena without fully settled naming conventions. As this and our companion piece describe, we take a broad view of CIE as the best single lens – to date – through which to understand a range of related activities and infrastructure. 

Similarities and Differences 

The table below compares HIOs and their HIE services with CIEs and their CIE services; this mapping represents core prototypes of each category and may not apply in marginal cases.  

Integrated or Complementary Services? 

Five or so years ago, one might have realistically imagined that HIOs would add CIE services – such as technology for community-level care coordination and closed-loop referrals between health and social services – to their offerings. Medicaid agencies in states like California and New York were pouring billions of dollars into the alignment of the Medicaid delivery system with social and human services to address social determinants of health and complex care needs, and data infrastructure was at a premium for this transition. Nevertheless, HIOs largely stayed in their clinical lane, while a new set of coalitions (CIEs, Whole Person Care Pilots, referrals networks, etc.) and vendors (closed-loop referrals, care coordination) emerged to meet the demand. This conservative approach by HIOs has been driven by the structural differences between their historical business model and the emerging CIE model documented in the table above and further elaborated here: from differences in participants and leadership, to data governance and consent, to distinct services. 

• • Participants and Leadership. HIOs are led by Boards of health care representatives from among their participating organizations, with little if any representation from social or human services; they naturally focus on clinical data exchange and workflows; to the extent that HIEs participate in cross-sector engagement, they typically do so from a health care perspective; 
  • Data Governance and Consent. Getting to “yes” for HIE has not been an easy road for most health care organizations, given legitimate concerns about data privacy and security and the use of data for competitive ends. While that set of debates has largely been settled in favor of data exchange, sharing clinical data with social and human services providers has introduced a new set of challenges. In California, state statutes and regulations specific to Medi-Cal’s Whole Person Care and CalAIM programs established a “safe zone” for cross-sector data sharing relative to state law. Even so, nearly all of these state-funded local efforts have also implemented comprehensive individual consent for data sharing that covers a broad, multi-purpose set of use cases including both HIE and CIE services. In contrast, most HIOs outside of states such as New York, which implemented an “opt-in” consent framework, do not obtain individual consent due to the perceived administrative burden. As a result, these HIOs, which include all HIOs in California, have essentially disqualified themselves from being able to offer CIE services at scale. This situation is unlikely to change unless there is action at the state level to both mandate and manage individual consents for cross-sector data sharing and collaboration.
  • Service model. HIOs are in the business of data collection, aggregation, and access. A baseline form of access is a read-only HIE portal with longitudinal, historical patient records. HIOs also deliver some patient data directly into their participants’ IT systems so that actionable information can be incorporated into providers’ workflows. In contrast, CIEs offer high-touch tools accessible through a user interface for care coordination with write-to and not just read-only functionality, and it is important for users to operate in the CIE platform itself. They do not attempt to provide comprehensive longitudinal records. To address workflow issues for providers who prefer to stay in their EHR, APIs can enable users to access the CIE platform from within their EHR, although such capability has not been broadly implemented. In any case, the provision of a user interface for real-time collaboration is a departure from the HIE service model of providing access to and delivering historical patient data. 

Due to these factors, we have not seen a single HIO in the country offer CIE services at scale – to all of its members and covering all of the population it serves through HIE. Instead, complementary rather than integrated services have emerged at the intersection of HIE and CIE where such innovative connections have been proactively pursued. In many cases, HIOs have acted as data-sharing partners to CIE efforts and their core vendors, pushing actionable clinical information to the CIE. This takes advantage of HIOs’ core service as clinical data suppliers, albeit to a new type of partner. A small number of HIOs in California have gone so far as to contract with care coordination platforms on behalf of County-led Whole Person Care pilots (we supported such developments in Humboldt, San Joaquin, and Santa Cruz Counties). These HIOs implemented focused data sharing between systems such as the delivery of hospital event notifications into the care coordination platform. Some other HIOs outside of California have begun to contract with closed-loop referrals vendors (including state HIE networks in Michigan, Arizona, and Colorado), but it remains to be seen how they will integrate such services with their core HIE offerings. In all of these cases, CIE services have been developed through parallel technical and governance infrastructure to HIE, rather than being integrated into the HIO’s governance and technical infrastructure for HIE. Alameda County’s Whole Person Care Pilot has perhaps gone the furthest, building a new Social Health Information Exchange from the ground up with its vendor partner UpHealth that offers many HIE and CIE type functions; the County is now in the process of exploring full HIO status within California’s structure for data exchange. 

Conclusion 

HIOs and CIEs share a number of important structural features, such as data exchange across organizations to improve services and outcomes, multi-purpose infrastructure, multi-stakeholder governance, and a value proposition driven by the density of participation among organizations serving a shared population. However, they have distinct service models, different participant and Board profiles, and the majority of HIOs that do not obtain patient consent have an additional barrier to merging CIE services with HIE. Given this confluence of factors, CIEs will likely continue to emerge as distinct coalitions and networks in many regions, while some innovative HIOs will contract with CIE vendors to offer specific CIE services for a subset of their members and population, positioning them to explore deeper integration over time. Across the board, given policy and market demand, HIE and CIE services will become increasingly complementary regardless of their organizational homes – while retaining their unique identities and functions.  

Considerations for HIOs that want to expand into CIE. HIOs are well positioned to play a key role in supporting CIE. Below is a list of some ways that HIEs may do so.  

• • If CIE exists in an HIO’s service area, the HIO may offer to serve as a supplier of relevant clinical data to the CIE. This provides a “single pipe” of clinical data to the CIE, saving the CIE tremendous time and effort in establishing inbound clinical data feeds. Data governance of clinical data shared with the CIE would become the responsibility of the CIE to manage, and this should be spelled out in the data sharing agreement between the two organizations.
  • An HIO’s Master Patient Index (MPI) is one of its most valuable assets, and this asset could be used to support identity management within CIE technology tools, which may not have either the same level of patient-matching sophistication or data for identity management.
  • Some communities with multiple vendor networks for social referrals have sought a technology solution to sit in the middle of these networks to direct referrals traffic between them. An HIO could either seek to develop this capability in-house or contract with a third-party vendor to operate such a function locally, potentially leveraging other HIO assets such as the MPI in the process.  This aligns with HIOs’ commitment to interoperability.
  • An HIO may be well positioned to mediate data exchange between different types of CIE tools as well (e.g. a care coordination system and a referrals system), or mediate a CIE’s ingestion of data from other relevant non-clinical data sources (e.g. Housing Management Information Systems, jail scheduling systems).
  • An HIO may be well positioned to receive specified data feeds from a CIE system to then aggregate social and clinical data and enable population analytics.
  • As seen in several examples above, an HIO may manage a procurement process and hold contracts with CIE vendors on behalf of the community.
  • In addition to holding contracts with CIE vendors, an HIO with a strong governance structure that can accommodate new members and voices from social and human services would be well positioned to consider serving as the CIE backbone organization in its community.
  • Conducting an assessment of the HIO’s governance, technology, and business models to evaluate the HIO’s readiness to embrace CIE could help HIO leadership consider how complementary HIE and CIE services could offer stakeholders cost-effective multi-program infrastructure. Understanding state and federal requirements related to consent, and a potential reconsideration of the HIO’s consent model to enable CIE use cases, may yield important insights on both opportunities and challenges ahead.  

Considerations for CIEs that want to leverage HIE. In the other direction, CIEs can leverage HIOs in the following types of ways (many of these correspond to an item in the list above, but from the CIE perspective). 

• • If a CIE effort is early-stage and has not identified a backbone organization, consider the local HIO as part of the selection process for this role. HIOs have years of accumulated experience with multi-stakeholder governance of critical data assets, and may be in an ideal position to expand their scope and leadership structure to serve as the CIE backbone organization.
  • Explore engaging an HIO as a supplier of relevant clinical data to the CIE. This provides a “single pipe” of clinical data to the CIE, saving the CIE tremendous time and effort in establishing inbound clinical data. Data governance issues, such as appropriate user access controls, are the responsibility of the CIE, and should be spelled out in the data sharing agreement between the two organizations.
  • An HIO’s Master Patient Index (MPI) is one of its most valuable assets, and this asset could be used to support identity management within CIE technology tools, which may not have either the same level of patient-matching sophistication or data for identity management. 
  • Some communities with multiple vendor networks for social referrals have sought a technology solution to sit in the middle of these networks to direct referrals traffic between them. If this is an issue in your environment, consider partnering with an HIO that could either seek to develop this capability in-house or could contract with a third-party vendor to operate such a function locally, potentially leveraging other HIO assets such as the MPI in the process. This builds on the HIO commitment to interoperability.
  • If contracting with multiple types of CIE vendors, consider leveraging an HIO to mediate data exchange between them (e.g. a care coordination system and a referrals system);
  • Look to the HIO to mediate your CIE’s ingestion of data from other relevant non-clinical data sources (e.g. Housing Management Information Systems, jail scheduling systems), if the HIO is able to accommodate such data.
  • An HIO may be well positioned to receive specific data feeds from your CIE system(s) to then aggregate social and clinical data and enable population analytics, resulting in cost-sharing for such functionality between the HIO and CIE.
  • Consider partnering with an HIO to serve as the contract-holder with all CIE vendors to centralize vendor management; if the CIE backbone organization is separate from the HIO, it would execute an all-in-one agreement with the HIO for these services;  
  • Conduct an assessment of the CIE’s governance, technology, and business models to evaluate readiness to engage with an HIO, ingest clinical data from the HIO, and effectively align services. If the HIO collects patient consent, evaluate whether the consent form and process can be expanded to support cross-sector collaboration and data-sharing. Consider how HIO and CIE alignment offers stakeholders cost-effective multi-program infrastructure. 

• ⁱ CIE ® is a registered trademark of 211 San Diego. For more information about the trademark, see the following webpages on the legal status and brand guidelines for the term. 

I am pleased to announce that Intrepid Ascent has reorganized our consulting teams into three groups: Technology Strategy, Policy Innovation, and Community Change. Our services will continue to be delivered by interdisciplinary teams, with resources drawn from each of these areas, but with one group at the forefront depending upon the challenge at hand.  

Defining our areas of focus in this manner provides three perspectives on the interconnected issues our clients face today as they integrate services across sectors to address social determinants of health and advance health equity. This definition also reflects the evolution of our focus over the past five years from health information exchange to broader community collaboration and the data infrastructure required to support it. Together, our groups provide clients with a commitment to understanding their technology needs and opportunities, navigating complex policy landscapes, and putting people at the center of change.  

Please read more about each of our groups here. Our group leads and I would love to hear from you with any ideas for how we might support you in driving positive impact. 

-Mark