A data-driven approach to whole person care

Riverside County relies on data integration and analytics from SAS to improve the health and well-being of vulnerable Californians

How do you ensure the most vulnerable populations receive coordinated medical, behavioral health and socioeconomic services they need in a way that benefits individuals, the community and the health system? According to Riverside County, you focus on the data.

Just east of Los Angeles in Southern California, Riverside County serves the health needs of nearly 2.5 million people. The county’s health facilities, integrated as Riverside University Health System (RUHS), includes a 439-bed academic medical center, an inpatient psychiatric facility and 13 federally qualified health care clinics.

In recent years, Riverside County has worked to improve whole person care (WPC) for probationers, an initiative funded by California’s 1115 Medi-Cal Waiver WPC pilot program. The program provides funding to counties to coordinate health resources with the goal of improving the health and well-being of Medi-Cal beneficiaries.

In Riverside County, probationers are typically high users of multiple county facilities and programs, yet they continue to have poor health outcomes. By integrating care for this vulnerable group, the county strives to give probationers the holistic care they need to live safe and healthy lives following incarceration.

“It’s common for individuals to leave jail without a stable environment to return to and no support system in place,” says Judi Nightingale, Director of Population Health at Riverside County. “They might be homeless, they might not have insurance, and they might be unaware of health conditions they have. Often, they end up in the emergency room or back in jail, which is detrimental to them and strenuous to the community. Our goal is to change that.”

The high potential of WPC

Riverside County’s WPC pilot program specifically aims to reduce emergency room visits and reincarcerations for probationers via screenings and referrals to targeted interventions and programs. Doing so directly benefits the individuals and society at large.

“It's really looking at how we can assist people in a way that helps them instead of being reactive and continually band-aiding whatever barriers they are facing,” Nightingale says. “This approach helps individuals successfully re-enter the community.”

But providing WPC care to any group is easier said than done. Keeping track of who uses what services across a health system and measuring the impact of those services toward health outcome goals is no small task. Adding to that complexity is the lack of a common electronic health record across Riverside County agencies.

“Although there's a great desire by different departments to work together and approach people as a whole and not a segmented person, it becomes really hard when you try to figure out the logistics on how to do that,” Nightingale says.

In addition, the lack of a data integration and reporting solution prevented Riverside County from accurately reporting the outcomes of its WPC pilot program to the state. This caused compliance and funding difficulties for county health officials.

Integrating health and non-health databases

Riverside County turned to SAS for support, and engaged with SAS to build a WPC solution based on SAS Data Preparation and SAS Visual Analytics on SAS Viya. The solution enables the county to integrate health and non-health data from its public hospital, behavioral health system, county jail, social services systems and homelessness systems.

“Before SAS, we had a massive data integration problem. Now we’re on track to receive $500,000 in WPC electronic data integration incentive payments,” Nightingale says.

By connecting these databases, Riverside County can now see how individuals interact with different services across its health system. This is enhanced by entity resolution, a feature of the technology that enables the county to identify unique entities, even if a person’s name, address or other personal identifiers don’t match up across different databases. Now, Nightingale and her team can map care pathways to health outcomes.

“We can look at specific variables tracked through SAS,” she says. “For instance, did a person show up to a service to which they were referred? Did they get that service? How long did they continue that service? We now have thousands of data elements in the SAS data warehouse, and we can analyze their relationships to each other to determine if a certain care pathway was able to reduce emergency room visits or reincarceration.”

Riverside County uses SAS Visual Analytics to evaluate its WPC program. The county benefits from self-service data preparation, allowing it to import its data, join tables and apply basic data quality functions via easy drag-and-drop capabilities. Combining advanced analytics, data visualization and data preparation capabilities helps Riverside County prepare data quickly for analysis.

By seeing what works and what doesn’t, Riverside County can make changes that advance its initiatives. Additionally, the SAS reporting tool enables the county to accurately report results to the state, providing the bonus benefit of maximizing program funding and incentive payments for meeting health outcome goals.

Operational gains with visual analytics

Prior to implementing SAS, Riverside County manually tracked the performance of WPC outreach engagement teams. For example, caseworkers must enroll a minimum of 50 people in Medi-Cal each month. As Nightingale explains it, tracking these metrics was hard work.

“It was very arduous to get that data, because we had several Microsoft Excel spreadsheets coming in from different locations, and they had to be cross-referenced to see if they were referring to the same people,” she explains. “Plus, the data was often delayed, and we were never sure it was 100% accurate.”

With SAS Visual Analytics, Nightingale can easily view performance metrics for nurses and caseworkers. “I love, love, love the dashboards,” she says. “It’s so straightforward – you don’t have to be a data specialist or IT expert to use it. For instance, you can set the set the date range for any data elements that you're searching for – like ‘show me all clinic data between Nov. 1 and Nov. 30, how many clients were case managed?’ And then you can drill down by clinic, and you can drill down by day or week, and then you can expand the search. It’s been an amazing tool for administrators to be proactive with caseworkers and other key team members. Now they can address trends reflected in the metrics that may indicate patient outcomes or compliance issues that should be tended to before becoming problems.”

As part of its SAS partnership, Riverside County uses SAS Remote Managed Software and Services, an arrangement whereby the county licenses the solutions to use on site while SAS manages them remotely. In effect, this augments the county’s capacity by using SAS experts to install the software, integrate the databases and build the reports. Throughout the process, county workers trained with SAS so they can operate the tools once the remote-managed engagement ends.

Flexibility to grow

According to Nightingale, the pilot program is only the beginning for WPC at Riverside County. Though state funding in its current form will eventually disappear, the population health director envisions a future where everyone in the county receives coordinated care to improve health and wellness outcomes.

SAS Viya gives Riverside County that flexibility to grow. The cloud-enabled analytics engine allows the county to scale its analytics environment through fast, distributed in-memory processing. This opens the door to expanding community partnerships, such as with universities and neighboring counties, to be able to further study what’s working and what isn’t.

“That's why I'm very excited about SAS,” Nightingale concludes. “If we can get an integrated look at every client and reduce our siloed efforts, we can get everyone in the county to their health and wellness goals more quickly.”