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Integration and Interoperability in a
Health and Human Services Enterprise
Montgomery County, Maryland | Department of Health and Human Services
October 7, 2013
WHO WE ARE:
Information about our County
Almost 1 Million
Residents
__________
31% Foreign Born
50.6% Ethnic Minority
17% Growth in our senior
population over the next
2years
49,344 out of 148,779
children in the public
school system receive
FARMS
6 Zip Codes of Extreme
Need — Poverty on the
Rise
Served 120,000
Households in Fiscal Year
2012. One-third used
more than two services
from Department
A Staff of 1,600 with
over 80 Programs
Caseloads Growing
TCA: 43.4%
SNAP: 166%
MA: 68.7%
Serving almost 36,000
uninsured adults,
children and pregnant
women
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Department of Health and
Human Services
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How is the Department Organized?
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In 1994, Four
Departments
Became One
Entity
OBJECTIVE:
Integrated,
Coordinated
and
Comprehensive
Service
Delivery
Montgomery County Department and Health and Human Services
Continuum of Programs
Aging and Disability
Services
Behavioral Health and
Crisis Services
Children, Youth and
Family Services
John J. Kenney
Chief
Raymond Crowel
Chief
Mental Health Services
Adults and Seniors
Children and Adolescents
Multicultural Mental Health
Services
Core Service Agency
Substance Abuse | Addiction
Services
Crisis Stabilization
Juvenile Justice
Partner Abuse
Victim Abuse
Boards and commissions
.. Alcohol and Other Drug
Abuse Advisory Committee
.. Mental Health Advisory
Committee
 Information and Assessment
Services
 Home and Community Support
Services
 Community Support Network |
Disability Services
 Home Care
 Adult Protective Services |
Case Management Services
 Nutrition Program
 Assisted Living and Skilled
Nursing Facilities
 Assisted Living Services
 Ombudsman Program
 Boards and Commissions
.. Commission on Aging
.. Commission on People with
Disabilities
.. Adult Public Guardianship
Review Board
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
Public Health Services
Special Needs Housing
Office of Community
Affairs
Kate Garvey
Chief and Social Services
Officer
Ulder J. Tillman
Chief and Health Officer
Nadim Khan
Chief
Betty Lam
Chief
 Linkages to Learning
 Child Welfare
 Child and Adolescent Services
 Early Childhood Services
 Gang Prevention Initiative
 Income Supports and Child Care
Subsidy
 Liaison Work with MCPS
 Boards and Commissions
.. Commission on Children and
Youth
.. Commission on Child Care
.. Commission on Juvenile
Justice
.. Citizens Review Panel
 Community Health Services
 Communicable Disease| BioTerrorism
 Cancer and Tobacco Initiatives
 Licensure and Regulatory
Services
 Assisted Living Facilities
Certification
 School Health
 Montgomery Cares
 Health Promotion
 Health Partnerships and
Planning
 Long Term Care Medical
Assistance and Outreach
 Special Projects
 Boards and Commissions
.. Commission on Health
.. Montgomery Cares Advisory
Board
Housing Stabilization |
Emergency Services to Prevent
Homelessness
 Economic Supports
 Emergency Assistance Grants
 Welfare Avoidance Grants
 60-Month Intervention
 Resource Supports
 Preventive Crisis Intervention
with Case Management
Rental and Home Energy
Assistance Program
 RAP - Shallow Rental Subsidy
Program
 SHRAP – Deep Rental Subsidy
Program
 Handicapped Rental Assistance
Program
 Home Energy Assistance
Program
Homeless Continuum of Care
Coordination
(Supported through non-profit
partners)
 Single Adult Shelters w|case
management
 Motel Placements and
Overflow Shelters
 Transitional Programs
 Permanent Supportive Housing




Community Action Agency
Community Outreach
Disparity Reduction
Diversity Initiatives and the
three Minority Health
Initiatives
 LEP Compliance
How is DHHS Organized?
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Moving towards single
client record supported
by an interoperable
database
One Director
Centralized
Administrative
Functions
Uniform intake form to
identify all service
needs
Designated entire HHS
entity as HIPAA
covered – including
social service and
income support
programs
No Wrong Door in the Future.
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
Seamless customer experience integrated in all 50
sites (27 program sites and 23 clinic sites)
Key to the experience will be:
 Access
to all DHHS Programs
 Shared information and data
 Customer telling their story once
TECHNOLOGY MODERNIZATION
An Aspect of Interoperability.
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Technology Modernization
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



Integrated Case Practices
Integrated Business Process
Enterprise-wide Client View
Improved Outcomes
Analytics and Individual Client
Focus and Population Health
Focus
The Process and Technology Modernization (PTM) Program lays the
foundation for changing DHHS service delivery over the next few years.
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Drivers




Changes in service delivery
best practice
Changes required by the
Affordable Care Act (ACA)
implementation
Difficulty/cost in maintaining
many one-off applications
supporting programs
Inefficiencies from using
multiple state systems
Goals






Improve client outcomes
Reduce overall costs of
treatment
Establish single platform for
most service delivery
Prepare for ACA-mandated
changes
Simplify ongoing application
maintenance
Realize vision of integrated
DHHS
Service Delivery Today.
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The PTM Program will help HHS transform from
disjointed, inefficient, program-based silos …
 Clients have to
Service Integration
“shop” for services
Treatment
Treatment
Treatment
Treatment
Treatment
Assessment
Assessment
Assessment
Assessment
Assessment
Eligibility
Eligibility
Eligibility
Eligibility
Eligibility
Intake
Intake
Intake
Intake
Intake
Aging &
Disability
Behavioral
Children
Youth &
Families
Public
Health
Special
Needs
Housing
Health
 No consolidated
view of client
engagement with
HHS
 Integrated service
delivery for only
the hardest-toserve clients
Service Delivery Tomorrow.
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… to a more integrated service delivery model
that treats clients holistically and cost-effectively.
Treatment
 No Wrong Door for
residents needing
services
Assessment
Eligibility
Intake
Aging &
Disability
Behavioral
Health
Client
Children
Youth &
Families
Public
Health
Special
Needs
Housing
 Consolidated view
of client
engagement across
most programs
 Integrated service
delivery where
appropriate
We adopted four guiding principles to
serve as touchstones as we move forward.
Because we
want to provide
seamless,
consistent services
to our clients
across HHS, we
seek to define
and implement
common
processing,
approaches and
methods
throughout HHS
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Because we want
to maintain and
upgrade our
systems over time,
we will leverage
the existing
functionality of the
software as fully
as possible and
minimize
customization
Because we want
to treat clients in
holistic, integrated
manner, we will
share information
about our clients
and their
treatment within
HHS, unless
prohibited by law
We will
never let the
perfect be
the enemy
of the good
The PTM Program includes 7 Interrelated Projects.
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IT Implementations
1.
2.
3.
Enterprise Integrated Case Management (EICM)
Enterprise Content Management System (ECMS)
Electronic Health Record (EHR)
Supporting Projects
4.
5.
6.
7.
US HHS Interoperability Grant
Organizational Change Management (OCM)
Project Management Office (PMO)
Quality Assurance (QA)
Target Phase 3 First Half
A
B
Application HUB (share application; eliminate dual entry)
Appointment
Eligibility
Check-in /
Registration
Application
Dependencies Determination
Scheduling
Clearance
Integrations/Conversions (single view of client)
Dependencies – CIS/SAIL integration – Person Query (existing), Person Registration, Case Query (existing)
Case Registration (CARES, OHEP), ECMS
Data conversion - CIS, CARES, OHEP
Subsumed
Appointment
Scheduling
Application
Eligibility
Determination
Program
Referral
Case
Assignment
WPA
ADS Risk Assessment
RAP
Service Area Customization
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Service Area /
Local Program
Specific
D
C
Registration
LotC
Common/Core
Functions
C
Check-in /
Clearance
Target Phase 3 Second Half
A
Application HUB (Add new sources)
B
Integrations/Conversions (Add new sources)
Service Plan
Provider /
Serice Match
Provider
Enrollment
Service
Referrals
(Manual)
Case
Dispensation
WPA
ADS Risk Assessment
RAP
Service Area Customization
Reporting/Analytics
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Service Area /
Local Program
Specific
D
C
Service
Strategy
LotC
Common/Core
Functions
C
Record
Assessment
Results
Conversion and Batch Integration Strategy
State/Federal
Systems of Record
Iterative Conversion Process
Integration with Systems of Record
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NIEM – Based Application Hub
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eICM
Case Management Modules
CASE MANAGEMENT
Automated in eICM
SERVICE TRANSACTION
Current process
Using System of Record
MANAGE CASE ACTIVITY
DELIVER UNITS OF
SERVICE
MANAGE CLIENT
PARTICIPATION
VERIFY CLIENT
PARTICIPATION
MONITOR CLIENT
PROGRESS
REPORT SERVICE
MILESTONES
MONITOR PROVIDER
FULFILLMENT
MANAGE SERVICE
BUDGET
INVOICE FOR SERVICES
RENDERED
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CM/ST Interactions
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eICM
Service
Referral
Provider
Batch Process
Service Transaction Details
Case Manager
State
System
of
Record
Service
Transaction
Details
CONFIDENTIALITY AND PRIVACY
An Aspect of Interoperability.
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Sharing of Information

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
Policy and Practice
Business Process
Need to Know
Role-Based Access
Balance between
Interoperability/Data-sharing and
Guarding against Breaches
Confidentiality:
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
Sharing
Information
within our
MultiService
Agency

Definition of treatment in the
regulations include “related services”
In context of our department, related
services include income support and
social services
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Addressing a client’s basic food or
shelter needs greatly impacts the
effectiveness of health care
Both the intent of the law and
language in the rulemaking process
supports this broad interpretation
Revised
Notice of
Privacy
Practices
Common
Resources
Training
Authorization
Form
Infrastructure
to Promote
Service
Integration
and Ensure
Privacy
Compliance
Minimum
Necessary
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Role-based
Access;
Access based
on a job
related
purpose
Department-
Wide Policy
(Example:
Safeguarding
Policy)
Why Integrate Data?
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Over 30% of our clients use multiple services
Clients often have to tell their story multiple times and
data has to be entered multiple times. Increases the risk
of errors in the re-telling and re-entering
Without a master client index, it is hard to tell what services a
client is getting across our enterprise and often services are
duplicated and there is waste and inefficiency
Makes re-use of data impossible and it makes it more
difficult for clients to access multiple services across
the enterprise
What is our Approach?
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We have a HIPAA Policy and Risk Manager leading an
office of 2.5 positions
Continuously updating and staying on top of the
federal and state policy environment
Continuously training and working to align policy
Our Process and Technology Modernization efforts
which include the following – ECMS, eICMS, EHR, MCI,
Legacy Systems and MCDHHS Portal will have policy,
business process and practice alignment for HIPAA,
42CFR and other privacy statutes and regulations
RETURN ON (TAXPAYER)
INVESTMENT/SOCIAL RETURN ON
INVESTMENT
Work led by JHU Public Health Informatics School
and Accenture
Slides attributed to Dr. Harold Lehmann
Background
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Application of cost-effectiveness analysis to human
services
 Washington
State Institute for Public Policy
 Evidence vs local data
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Decision oriented
 Klazinga,

et al. Int Soc Qual Heal Care 2001
Social return on investment
 Cresswell;
sroinetwork.org
Architectural
Model
Outcome Measures
Costs
Benefits
vaticanus
Case
To Be
As Is
RO(T)I Results
Standard Practice
Costs
Incurred
Test case 1
Homeless
Test case 2
Youth in Transition
Costs
avoided
With Interoperability
Costs
Incurred
Costs
avoided
Net
Monetizing Impact:
Net Benefits by Stakeholder
Criminal Justice Cost Breakdown
Arrest (Sheriff)
Local
County Attorney
State
District Court
Federal
Other
Public Defender
0%
20%
40%
Dakota County
Cost
Cost 1
Cost 2
…
Total Cost of RAP
Jail
Benefit
Arrest
(Criminal
Probation
Justice Cost
…
Avoidance)
Total Cost Avoidance Attributable RAP
Benefit
(Community Benefits Not Quantified
Impacts) Tax Revenue Attributable to RAP
Totals
Total Benefits
Total Costs
Total Net Benefits
60%
Other Counties
80%
100%
State of MN
Federal
Other
TOTAL
Variables: Functional Model
Costs
Benefits
Case
• Service costs
• Data costs
Protocol
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Upper model: Trace provenance of data
Functional model: Interviews at generic level
Database model: Review database schemas
 Result:
 Trace
data from creation to storage to outcome, along with
costs: Interoperability model
 Articulate benefits (as represented by the data)
ROTI, SROI:Based on nef, 2006
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Understand and plan 
Stakeholders
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Boundaries
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Impact map, indicators 
SROI plan
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Nef=New Economics Foundation (UK)
Collect data
Projections
Analyse income, expenditure
Calculate SROI
Report
<Cycle>
Questions Raised
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What are the IT decisions that matter?
How far can we get with generic data?
Issue of monetizing the “upper model” outcomes
The biggest costs for the system as a whole are from
NICU stays for premature babies. But those costs are
not in our universe.
“Minimal modeling” (David Meltzer): Value ×
Durability × implementation × incidence ×
population.
What are the Markers of Success?
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A seamless integrated Health and Human
Services environment
Integration at the point of intake and
assessment
Integration at the point of service delivery
Collaborative case practice when case
acuity is severe
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Improved client and patient outcomes

A more equitable service delivery system

Strong population health and program level
data and analytics capabilities in addition
accessible case specific data
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Questions | Answers | More Information
Uma S. Ahluwalia, Director
Department of Health and Human Services | Rockville, Maryland
240.777.1266 | uma.ahluwalia@montgomerycountymd.gov