Healthcare IT News: Health system takes an ‘Epic first’ approach to integrating all data, including SDOH

Recognizing that medical services only address part of a person’s overall health, the California Department of Health Care Services designed the Whole Person Care program to address the physical health, behavioral health and social needs of high-need, high-cost Medi-Cal beneficiaries.

DHCS negotiated the program as part of its Medi-Cal 2020 Section 1115 waiver renewal with the Centers for Medicare and Medicaid Services. The WPC pilots are testing whether local initiatives coordinating physical health, behavioral health and social services (housing supports, food assistance, other public benefits, etc.) can improve health outcomes and reduce medical costs.

Up to $1.5 billion in federal funds are available over the five years of the program, matched by $1.5 billion in local funds from the pilots. Each WPC pilot differs in size, target population(s) and interventions based on community needs, priorities and resources.


Factors in the local economic and community landscape in 2016 drove the urgency for Contra Costa Health Services in applying for the WPC grant. At the time, overcrowding for low-income renters was 43% above the national average, approximately 17% of residents were living at or below the poverty level, and high housing costs required a significant portion of an individual’s income.

“Pay required to afford average rent in the county was $34 an hour and yet minimum wage remained at $9 an hour,” said Sue Crosby, whole person care program director at Contra Costa Health Services. “Coupled with this economic landscape, an increase in Medi-Cal eligible residents exacerbated existing problems in the fragmented system – primarily seen through increased appointment wait times and ineffective utilization of the county’s emergency departments and hospital systems.”

The county’s low-income and vulnerable residents were disproportionately suffering from poor health outcomes stemming from unmet social, behavioral and healthcare needs. In screening for social needs in Contra Costa Health Services clinics, 50% of patients queried had one or more social need, including food, housing, health, utilities, employment, transportation, child care and education.

“Contra Costa Health Services capitalized on the opportunity to develop a large-scale social case management program for high utilizers of multiple systems,” Crosby explained. “As the primary backbone to support this and the other grant aims, Contra Costa Health Services also applied for significant funding to expand and better utilize the existing data systems in place.”

This involved bringing siloed divisions into the central data landscape through expansion of the existing Epic infrastructure where possible, and where not, improving the technology and integrating into a centralized data warehouse, Crosby added.

“Contra Costa Health Services was awarded $200 million over the duration of the grant from 2016-2020,” she said. “Areas of focus in the pilot have included using data to automate time-intensive processes, sharing data with a more diverse range of partners, and equipping frontline workers with data to target and improve the services they provide.”


The Epic EHR has been used as the record system at Contra Costa Health Services for more than seven years, and the WPC program included a rollout of Epic to new types of care settings in order to create a comprehensive record for patients.

“Contra Costa Health Services originally implemented Epic in 2012 across its ambulatory clinics, hospital, detention health program, health plan and parts of its public health program,” Crosby recalled. “Part of the funding from the WPC program was used to extend Epic to behavioral health in order to include outpatient psychiatry care in the shared health record.”

It was also used to extend Epic into the social case management program. By integrating support for behavioral health and social needs within Epic, patients have one centralized record that incorporates key factors that affect their physical health and well-being. This enables their caregivers to collaborate across disciplines to address patients’ full spectrum of needs.

“Contra Costa Health Services also connected Epic and other systems with the county-managed data warehouse in order to develop more comprehensive predictive models,” Crosby explained. “This warehouse includes data from social services and the Homeless Management Information System.”


There is a variety of electronic health records systems on the market today. Some of the vendors of these EHRs include AdvancedMD, Allscripts, athenahealth, CareCloud, Cerner, eClinicalWorks, Epic Systems, GE Healthcare, Greenway Health, McKesson, Meditech and NextGen.


The first part of the effort was patient identification, a risk model. Patients are qualified for enrollment by meeting certain requirements.

Patient identification

“For example, they must be over 18, covered by Medi-Cal and a Contra Costa County resident,” Crosby explained. “Patients who meet the requirements are evaluated using a predictive model developed with the help of a data scientist and evaluation team that aims to identify the future likelihood of avoidable emergency department or inpatient admissions.”

The regression-based predictive model targets potentially avoidable emergency department use and inpatient admissions using data available from a variety of county and community data systems. All qualified patients receive a risk score and are ranked. The top 25,000 patients are identified as eligible for the program.

“The model has been refined throughout the pilot and currently includes more than 80 variables,” Crosby said. “In order to evaluate program effectiveness in terms of utilization outcomes, a similar risk population is identified at the point of enrollment and patients are randomly assigned to the enrolled (i.e. intervention) group or the control (i.e. usual care) group. The control group is eligible for intervention enrollment in subsequent months.”

Automated patient enrollment and registries

Then come automated patient enrollment and registries. Eligible patients are enrolled in the program each month via an Epic DataLink connection from the Contra Costa Data Warehouse to Epic to place the patient in an enrollment registry.

“Clients identified as high-risk are automatically enrolled and assigned to an appropriate case manager from one of more than 100 direct service case managers comprised of multiple specialties – a matching process optimized with the help of relevant data, such as clinical history and geographic area, stored in the county’s data warehouse,” Crosby said.

Contra Costa Health Services has fully automated the enrollment process, saving more than 350 hours each month, she added.

Social case management tools

Up next are social case management tools. More than 100 direct service case managers were hired and trained for this program throughout the county. They are supported by multidisciplinary teams for cross-specialty support and consult.

These case managers support more than 14,400 patients every month. Some case managers work by telephone and others work in the field. All case managers connect to service providers throughout the health system and document their activities within tools built in Epic.

“These tools include a social needs screening SmartForm and interactive care plan development through Epic’s Patient Goals functionality,” Crosby explained. “Best Practice Alerts prompt case managers to create Patient Goals based on positive social needs identified. Within each Patient Goal, SmartText templates with embedded discrete SmartData elements guide case managers in documenting resources provided and status updates over time. All information is transferred to Epic’s data warehouse, Caboodle, to assist in program evaluation.”

In 2016, when the program grant began, Epic did not have all of the tools Contra Costa Health Services needed related to addressing patients’ social determinants of health. Since then, Epic has worked closely with Contra Costa Health Services to better understand the WPC program, design tools to fit the program’s needs, and learn how to apply these tools at other health systems, she said.

Interactive Qlik dashboards

Then comes interactive Qlik dashboards integrated into Epic. Analytics dashboards tailored to each case manager are presented upon initial login into Epic.

“Case managers are able to see newly enrolled patients added to their caseload as well as track key milestones for their caseloads of 90-350 patients,” Crosby stated. “These dashboards were developed in Qlik using human-centered design principles and are interactive to allow case managers to directly open a patient’s chart to complete outreach, follow-up or correct documentation. The core aim of the dashboards was to equip frontline workers with data to understand, target and improve the services they provide.”

Dashboards have also been developed for management staff to oversee case managers and program administration to track program trends and metrics, she added.

The interactive Qlik dashboards are followed by a visible and dynamic care team list. Whole Person Care case managers are automatically added and removed from Patient Care team upon admission or discharge and are visible to the entire health system and neighboring organizations through Epic’s interoperability network, Care Everywhere.

Care team members from partners not using Epic, such as Public Health Nursing and Homeless System partners, are interfaced into Epic.

Real-time notifications of admissions

Then come real-time notifications of admissions to Contra Costa and neighboring health system facilities. InBasket message notifications to case managers through Care Everywhere alert staff to critical events in the patients’ lives.

“This allows case managers to follow up to ensure the patient understands their discharge instructions, provide support at a critical time and, in some cases, educate the patient on more appropriate levels of care,” Crosby said.

Direct integration with social domain partners

The next aspect of the effort is direct integration with social domain partners. Contra Costa Health Services was committed to designing workflows for the case manager to remain within Epic for all documentation and patient care needs wherever possible.

“Recognizing that the world of social case management is heavily dependent on community and specialty partners, integration with supporting social domain areas was completed as well,” Crosby said. “Bay Area Legal Aid is contracted with the pilot program to provide 2.5 attorneys full-time to support legal needs of patients. To better facilitate communication and referrals to this organization, the program developed a SmartForm in Epic to capture specific legal needs, which is then securely shared with the partner agency.”

An outbound demographics interface was established with RoundTrip, a third-party transportation broker, to pass key patient information to the HIPAA-secure platform and open the application from within an Epic encounter. After launching from Epic, case managers are able to book rides for the patient to support transportation needs. The program is currently using Lyft and taxis to provide more than 1,200 rides monthly to patients.

Contra Costa Health Services partnered with Sprint to provide cell phones to a subset of enrolled patients with full data and service plans. Case managers request cell phones for patients through Epic referral orders to WPC program administration.

The smartphones have been preloaded with apps to support program aims of physical, behavioral and social health. Service has shown higher levels of patient engagement than those without program-provided phones.

Epic rollout to behavioral health

Then came the Epic rollout to behavioral health. The mental health clinics within the behavioral health division of Contra Costa Health Services were some of the last organization entities to transition to Epic, in September 2017, with the support of WPC funding.

Before that time, outpatient psychiatry record keeping and clinical notes resided in paper charts. As part of the commitment to WPC, the county decided to share mental health information widely with care providers using the electronic health record.

“In order to facilitate information sharing, the county rolled out the EHR to the ambulatory mental health departments, and implemented Sharecare for behavioral health billing for community-based service providers outside of the county health system,” Crosby recalled. “Summaries of this information are interfaced back into Epic, allowing care teams to understand services provided in the community.”

As a result, providers can now access a complete picture of mental health services by all providers in a central location, she said.

Data sharing and bulk communication

Up next: Data sharing and bulk communication to support continuing Medicaid coverage. After developing a data-sharing memorandum of understanding, the social services system (EHSD) is able to share Medicaid program information on enrolled clients to retain and restore coverage.

The upcoming date of redetermination is linked to Epic and included on a report so that case managers are aware of upcoming redetermination dates and can support clients in turning in key paperwork to continue benefits.

In addition, the program uses Epic’s bulk communication and outreach tools to proactively send brightly colored flyers to patients alerting them of this upcoming event and providing education on what to look for in the mail and the importance of prompt response to the Medicaid program communications.


Contra Costa Health System successfully brought new and relevant data streams into the county data warehouse. The warehouse receives data from sources outside of the EHR system, but also feeds the EHR system with specific data elements from outside systems.

Data exchange occurs between the EHR and the Homeless Management Information System (HMIS) for housing and homelessness information, Sharecare for behavioral health utilization and claims, Persimmony for public health nursing programs, the emergency medical services (EMS) system, CCHP claims, and prescription fills from outside pharmacies.

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