ECCOVIA, INC.
SALT LAKE CITY, UT

Now is an exciting time for Medicaid technology. State Medicaid programs have long pursued greater coordination and integration of care in order to improve care outcomes, improve the quality of care, and reduce overall costs. In the last few years states have begun developing new delivery system strategies to improve care coordination and integration among traditional and community-based Medicaid providers. In addition, The Centers for Medicare and Medicaid Services is encouraging the adoption of modular, reusable software solutions in order to accomplish this. Behavioral health providers must consider the full spectrum of their patients’ condition, including crucial aspects of physical health, mental health, substance abuse issues, chronic conditions, and the social determinants of health that impact patient outcomes. ClientTrack Case Management for Behavioral Health helps providers manage multiple complex aspects of the patient condition to deliver better care. Assisting clients who have intellectual or developmental disabilities presents some of the most challenging case management situations. Caregivers must ensure appropriate care is provided around the clock, day in and day out to patients who may be unable to assist with their own care plan. And not only must the care be provided but it must be accurately recorded and documented for billing purposes. Prisoner reentry programs are critical in helping released inmates obtain the base of support needed to productively integrate back into society. Workforce Services plays an important role in addressing the social determinants of health. Obtaining and maintaining employment provides an important foundation for improving health outcomes for vulnerable populations, (i.e. individuals experiencing homelessness and the intellectually and developmentally disabled). Workforce services agencies often must manage complex sets of information as they collaborate with employers, schools, and community health providers. Products The ClientTrack platform is natively designed for today’s collaborative model of care. While many electronic health systems narrowly focus on one aspect of care, ClientTrack incorporates an advanced case management system, flexible database, engagement portal, and reporting and analytics. Information across the full spectrum of the social determinants of health is collected and tracked, leading to better-informed care decisions. Providers no longer have a limited view into their client’s condition. Information collected from any point of care is available to all authorized users. In order to incorporate the social determinants of health into healthcare decisions, the information must be readily available. ClientTrack places critical information in the hands of all care providers through a shared platform that combines elements of case management and healthcare delivery. The ClientTrack Online Portal enables clients to report progress updates through the portal with providers and care coordinators who are reviewing the updates and collaborating on next steps. At Eccovia Solutions we love to highlight the great work our clients and partners are doing to provide patient-centered care in their communities. The Los Angeles County Department of Health Services is building an integrated, county-wide health system that delivers coordinated wrap-around services to approximately 80,000 of the most vulnerable and high-risk individuals living in the county. On June 30, Dr. Clemens Hong, MD, MPH, Director of Whole Person Care and Medical Director of Community Health Improvement, joined Neal Howard from Health Professional Radio to discuss their innovative program. We are pleased to provide a segment of that conversation here. Dr. Hong: The Whole-Person care pilot program is part of the 1115 Medicaid waiver which is a contract that the state of California signed with the Centers for Medicare and Medicaid services to provide Medicaid services here in California. Part of this was a pilot program that they put into place to take care of some of the sickest and most vulnerable residents at the county level. The funds are provided to county departments to serve a subset of the highest risk individuals that we serve in our county (individuals who are homeless). In our case in Los Angeles, the individuals may be justice involved, suffer from serious medical illness, substance use disorder or significant medical illness. This group of individuals (through the Whole-Person Care pilot) have an opportunity for additional services that many would put in the sphere of care management or care coordination services. Dr. Hong: This is where we have really done a lot of thinking and work with a partner of ours, which is Eccovia Solutions and their ClientTrack tool. It is a platform that we are trying to put on the ground here to really solve a lot of these, I would say, dis-integration issues in the way that information and health information is shared among different teams that are out there trying to provide coordinated care for these individuals. Like you alluded to, these are not the average clients that have any handful of issues that can be addressed predominantly in one or two settings. These are individuals that often have multiple case managers working across multiple settings. This raises the need not only for information sharing but also a place where, perhaps, something such as a care plan—which is a place where we’re actively creating different activities and action steps that we are working with a client on—can be shared in views, so that multiple case managers and individuals involved in care can see what the status of any of the given application or set of services. For instance, if we wanted to refer someone to a food program like Snap, we could follow the status of that through one platform so we don’t have multiple case managers in three settings submitting applications. This is made possible in our system through a series of IT platforms, but one really critical piece is that front-end platform that we contracted Eccovia Solutions for. It really allows us to keep that care plan in one place and—through a portal—make that care plan accessible to others. You alluded to some of the challenges in terms of data and sharing that data; we put together a robust consent process here, working with our county council, and this process will be managed with the support of this IT platform.