By KATHLEEN NELSON
A homeless veteran struggling with substance dependence may not have the energy or resources to coordinate social and medical services that could open a path back to mental health, economic stability and sobriety. Likewise, the parents of a child with mental illness or developmental delays may be confounded by a lack of coordination among schools, social service providers and medical providers.
A partnership between Mercy Northwest Arkansas and the Endeavor Foundation is using a technology platform to dismantle those obstacles to coordinated care and ensure that individuals and families don't get lost in a disconnected system. Endeavor is a community foundation that supports health, human services and education projects in the region. The partnership is opening lines of communication across those sectors and giving community members easier access to knowledgeable people who know how to connect the dots between those community resources.
Nick Ogle
"Providers from mental health to housing to dental to education are faced with overwhelming community needs and searching for a better way to collaborate," said Nick Ogle, director of mental and behavioral health at Mercy Northwest Arkansas.
Before building the technology platform, Mercy and Endeavor conducted a yearlong needs assessment that included 3,500 interviews and surveys with parents, teachers, education administrators, and medical and social service providers. Investigators evaluated the state of mental health, physical health and social services offered to children, other individuals and families in the region.
The results were shared with Mercy and two other regional health systems, the community mental health system, schools and the region's health departments. As most suspected, communication across sectors was almost nonexistent, and agencies used a variety of record-keeping methods, or none at all. Keeping track of clients was difficult at best and often led to gaps or delays in delivering services.
"Providers were working in silos," Ogle said. "Moving clients from Point A to Point B, there's no clear pathway to deliver coordinated human services."
Collective impact
To develop those pathways, Endeavor provided a $6 million grant to Ogle and his team to set up HARK at the Center for Collaborative Care in 2016.
The center's approach is based on the concept of collective impact, which brings groups together to advance common goals and facilitate communication among people working in different sectors — in this case, clinicians, behavioral health specialists, caseworkers, teachers and education administrators. Hence, Ogle refers to the center as "a backbone organization" for social service stakeholders in Northwest Arkansas, including patients and clients.
The center built HARK, a centralized information technology platform and participating institutions agreed on how they would measure progress in coordination of care and services.
The HARK information technology platform developed in partnership between Mercy Northwest Arkansas and the Endeavor Foundation is opening lines of communication among providers of social services, medical care and education in order to coordinate care and make it easier for people to access services.
HARK, a cloud-based platform, connects people in need of social services with providers. The goal is for individuals and families to use the tool to knit together and take ownership of their own care community. Users build a personal profile, identifying their needs and goals. The platform can be accessed through any Internet-capable device.
Providers also build profiles on HARK that detail their services for clients and fellow providers. Prospective clients use that information to find services that meet their needs.
HARK also includes free case management software, which has been essential for small and medium-sized organizations that lack a record-keeping platform of their own.
The software's posting boards "function almost like a social media platform for casework," Ogle said. "So a doctor at Mercy, for example, can post a test result that a client's caseworker at the VA can use in applying for aid. We're trying to find a more effective way to move the information that all care providers need."
Privacy controls
The platform complies with the Children's Online Privacy Protection Act, the Health Insurance Portability and Accountability Act and the Family Educational Rights and Privacy Act. A client can sign in and agree to have sectors share information. For example, a veteran who is homeless might agree to allow the VA, a shelter and hospital to have shared access to his or her records.
"It's not a free-range health exchange," Ogle said. "We let clients decide who has access to their records."
Since the launch of HARK in the summer of 2017, 1,500 individuals or families have set up accounts.
Community liaisons
HARK has hired 13 "high-level case managers to get people connected to multiple organizations," Ogle said. These community liaisons work with individuals and families to explain the array of services available in the region, help them build a personal profile and show them how to set up a care team through the digital platform.
The liaisons are stationed in Springdale, Rogers, Bentonville, Siloam Springs and Fayetteville, so they are closer to schools, libraries and health facilities where they can encourage people needing services to set up a HARK profile online.
In the past year, Ogle said, community liaisons have worked in some capacity with 2,000 people, teaching them either about the app or about how to access specific services.
Provider collaborations
Ogle and his team faced a challenge in getting social service providers to get to know each other and the services they offered in order to establish a "no wrong door" approach to services for community members.
"We had to help them with ways to get people from their lane to other lanes," Ogle said.
The center hosts workshops at least once a month as well as an annual conference called Coordinate NWA, focused on how providers throughout the region can use HARK to better coordinate care and share data. Since HARK's launch, Ogle said, 1,300 individual social service providers from 430 organizations have signed up and use the technology to record and communicate data.
Mercy's continued involvement
Ogle holds dual appointments, continuing in his role at Mercy while working as the center's executive director. "Mercy has been our pilot," he said. "Mercy serves as this amazing opportunity to keep trying things on the medical side."
For example, a community liaison is posted at Mercy Behavioral Health. Another liaison communicates daily with hospital and clinic case managers and social workers to help patients access housing, food and legal assistance.
Mercy has clinicians, therapists and nurses using the HARK technology system to communicate with the nonprofit social service providers and educators in the area.
Still to come
Mercy also plans to direct a pilot program in which caseworkers follow up with patients who frequently visit emergency departments, assessing their needs and helping them connect with resources in the hope of reducing ER visits.
The data collected from the case management software has started to show what Ogle calls "clear paths for services. If a client comes to us from the VA and is homeless, we've learned they need x number of services. That matrix is starting to be built in now, making it easier to set up services and appointments."
Plans also are in place to embed community liaisons in Fort Smith and Clarendon.
Perhaps most exciting to Ogle is "digging deeper into the well of provider touchpoints."
Teachers, faith leaders and first responders serve on the front lines of need, yet they lack clear paths within their own institutions to participate in coordinated care of an individual.
"Expanding our efforts to connect and coordinate with these professionals and reducing barriers of participation are crucial to the holistic and seamless care system we imagine," he said.