A Life of Possibilities with the Coordinated Care Platform

A Life of Possibilities For All Virginians

Challenge:

The Commonwealth of Virginia Department of Behavioral and Developmental Services (DBHDS) manages a public mental health, developmental disability and substance abuse disorder services system comprised of 14 state facilities and 40 locally-run Community Service Boards (CSB).

In their vision to support “a life of possibilities for all Virginians,” the DBHDS is responsible for the oversight planning, direction, development, funding and monitoring of the mental health system. This includes leading the initiative to transform their facilities and services to embrace more community-based care for persons in need.

With requirements to transition capable individuals from state-run intellectual and developmental (IDD) training centers back into the community, Virginia elected to replace their manual, paper-based system with automated case management for a more secure, global view of the individual in order to facilitate safe and accountable transitions of care.

Using the existing paper-based system, Virginia’s five IDD centers as well as contracted community providers and the CSBs were in disconnected data silos. Health records weren’t easily shared among providers, and activities and efforts on behalf of the individual weren’t being effectively tracked.

Solution:

To ensure the safety of the transitioned residents, the DBHDS developed a strategic Community Integration Program, which provides a support infrastructure for individuals with IDD to be fully integrated into the community from one of the five training centers to more independent living environments managed in collaboration with the CSBs. As part of this initiative, Virginia uses the Coordinated Care Platform for automated case management to handle discharges and transitions of care statewide.

Before resident transitions, the DBHDS works with the individual and their family or authorized representative to identify needed supports along with any provider organizations that can meet those needs. After the resident and their representative(s) select a community provider organization, staff from the DBHDS, the IDD training center and the local CSB work with the selected provider organization to implement the person-centric discharge plan.

The CSBs use the Coordinated Care Platform to track each individual to ensure that the transition process and community-based services selected meet requirements and mandates. With the CCP, Virginia behavioral and mental health providers record, track and report mission data to facilitate intensive case management and monitoring for individuals in transition in addition to tracking and documenting the duties assigned to staff members serving each individual during and after the transition.

The Coordinated Care Platform provides Virginia behavioral and mental services with a holistic and integrated electronic health record, enabling documentation and secure, role-appropriate sharing of person-centric transition, treatment planning and follow-up monitoring information. The CCP also supports scheduling and documentation of visits by CSB case managers and DBHDS licensing and human rights staff to monitor the individual’s adjustment to their new setting.

Additional features support individualized assessments and treatment planning; prescription management for medication safety; secure data exchange with community providers and case managers; real-time incident management and reporting according to Virginia’s protocol; post-discharge monitoring, engagement and coordination of services with CSBs and private caregivers; and robust yet flexible system Dashboards and reports for on-demand aggregate population and individual results monitoring.

As part of the engagement, the CCP team and the Virginia DBHDS also worked together to create the Virginia Assessment Tool. The new VAT is a customizable assessment used by the IDD training centers and the CSBs to standardize state-mandated assessments. Leveraging the ease of configuration offered by the Coordinated Care Platform, Virginia now has a more transparent and complete view of all individuals they are helping transition back into the community.

Results:

The Web-based Coordinated Care Platform provides the Virginia DBHDS and CSBs throughout the state with a behavioral health-centric solution for centralized data sharing among all the key players in an individual’s Care Plan. The CCP has also helped decrease transition barriers and document all transitional activities, enabling Virginia to optimize the delivery of services and improve outcomes as well as measure and report on progress for accountability.