SUBJECT
Title
RECEIVE UPDATE ON SUPPORTING CARE COORDINATION FOR JUSTICE-INVOLVED INDIVIDUALS: DATA GOVERNANCE AND INTEGRATION AND AMEND REPORT BACK SCHEDULE (DISTRICTS: ALL)
Body
OVERVIEW
Individuals involved in the justice system often face challenges such as homelessness and lack of health insurance which makes accessing and adhering to health and social service programs difficult. In turn, this creates a challenge to receiving ongoing care and treatment of health conditions among this population. Additionally, data indicates that justice-involved individuals are among the most underserved in society, which contributes to poor health and social outcomes, such as significantly higher rates of infectious disease, chronic physical and behavioral health conditions, and homelessness. These disparities underscore the importance of care coordination for justice-involved individuals and pursuing all actions that support enhancing the ability to connect individuals to the care and services they need.
Recognizing the challenges faced by justice-involved individuals, and to demonstrate their commitment to addressing inequities and health disparities that impact this population, on May 10, 2022 (3), the San Diego County Board of Supervisors (Board) approved Supporting Care Coordination for Justice-Involved Individuals Through Funding and Integrated Data Infrastructure. This Board action acknowledged the challenge of coordinating care across justice, health and social service sectors and requested a report of challenges and opportunities for data integration and a proposed data governance structure. On February 28, 2023 (20), the Board received and approved a report entitled Supporting Care Coordination for Justice-Involved Individuals through Funding and Integrated Data Infrastructure: Report on Potential Opportunities and Challenges Impacting Data Sharing, acknowledging the challenge of care coordination across justice, health and social service sectors without a data governance structure and integrated data system.
Today’s action proposes a data governance structure and provides updates on data sharing and integration efforts to support care coordination of justice-involved individuals. The proposed data governance structure includes a plan for a six-month pilot with a subsequent report to the Board in early 2024 to update on progress.
Today’s actions align with the County of San Diego’s vision of a just, sustainable, and resilient future for all, specifically those communities and populations in San Diego County that have been historically left behind, as well as our ongoing commitment to the regional Live Well San Diego vision of healthy, safe, and thriving communities. This will be accomplished through collaborative efforts that support coordination of care for those involved with the justice system, ultimately leading to improved health and well-being outcomes, and contributing to the reduction of health disparities and inequities impacting this population.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Receive an update on Supporting Care Coordination for Justice-Involved Individuals through Funding and Integrated Data Infrastructure: Data Governance and Integration.
2. Amend the report back schedule as described in the May 10, 2022 (3) San Diego County Board of Supervisors action to eliminate the requirement of every 180 days and replace it with a report back in early 2024.
EQUITY IMPACT STATEMENT
On January 12, 2021 (8), the San Diego County Board of Supervisors (Board) adopted a resolution declaring racism a public health crisis and took bold action to tackle this issue to improve the overall health and well-being of San Diego County residents. Establishing a data governance structure to facilitate data sharing related to care coordination for justice-involved individuals is an important step in supporting the Board’s commitment to addressing this issue. In 2021, Black individuals accounted for 17% of all arrests in San Diego County while representing 5% of the adult population in the same year. Hispanic individuals accounted for 35% of all arrests while representing 32% of the population. White individuals represent nearly half of San Diego County’s population and accounted for 41% of all arrests. Race and ethnic-based disparities within the criminal legal system, and their correlation to poor health, social and economic outcomes, underpin the importance of data collection and sharing to address trends, enhance care coordination, dismantle systemic contributors to disparities, and improve health outcomes for all. The County continues to advance efforts to address inequities and reduce disparities that impact justice-involved individuals and improve health outcomes for this population.
Additionally, individuals who are justice-involved experience adverse health and socioeconomic outcomes at greater rates than the general population. Data shows that rates of chronic conditions among incarcerated individuals are more than double that of the general population and nearly two-thirds of jail inmates have substance use disorders, as compared to 5% of the general adult population. In addition, rates of mental health disorders have been found to be nearly four times higher among individuals in jail compared to the general population, and substance use disorders were found among more than 50% of the inmate population.
It is important to consider how policies, procedures, and systems impact the justice-involved population. Reaching equity requires addressing the social, political, and economic factors that impact justice-involved individuals’ ability to access care and services. Including community stakeholders and/or individuals with lived experience within a data governance structure focused on supporting care coordination for those involved with the justice system will aid in considerations of how policy and system designs impact this population. Increasing data sharing may also increase opportunities for monitoring outcomes with an equity lens and facilitate the exchange of information to enhance individuals’ access to the care and services they need, with a goal of improving the social and economic situations in which this population may find themselves.
SUSTAINABILITY IMPACT STATEMENT
Supporting care coordination for justice-involved individuals supports the County of San Diego’s (County) Sustainability Goal #1 of engaging the community, as capturing the community’s voice and including individuals with lived experience are critical components of the proposed data governance structure. This item also supports the County’s Sustainability Goal #2 of providing just and equitable access by creating a data governance structure to enhance care coordination, connecting individuals with services and supports more quickly to ensure needs are addressed. These efforts collectively help improve connection to services that reduce recidivism and promote health and well-being by ensuring the alignment of needs, resources required, and outcomes.
FISCAL IMPACT
There is no fiscal impact associated with this action. As a result of outcomes of pilot and resource assessment to be completed, there may be future fiscal impacts and staff would return back to the Board for any such recommendations for consideration and approval. Funding for future costs will need to be identified prior to further action. There will be no change in net General Fund costs and no additional staff years.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
Due to a lack of quorum, the Health Services Advisory Board meeting on May 4, 2023 was canceled and this item was unable to be presented. The item will be presented as an informational item at a future meeting in 2023.
The item was presented as an informational item during the May 4, 2023 Behavioral Health Advisory Board meeting.
BACKGROUND
Justice-involved individuals experience adverse health and socioeconomic outcomes at greater rates than the general population. Data shows that rates of chronic conditions among incarcerated individuals are more than double that of the general population; nearly two-thirds of individuals in jails have substance use disorders, as compared to 5% of the general adult population. According to the Regional Task Force on Homelessness 2022 Jail Point-In-Time Count, 31% of inmates experienced homelessness prior to incarceration. This indicates a significant overlap between people experiencing homelessness and justice-involved populations. Every day, justice-involved individuals are released from custody and are in need of care coordination. Sharing data to support care coordination helps individuals and care managers navigate complex health, justice, and social care systems, which can be a lengthy and disjointed process.
On October 19, 2021 (3), the San Diego County Board of Supervisors (Board) approved A Data-Driven Approach to Protecting Public Safety, Improving and Expanding Rehabilitative Treatment and Services, and Advancing Equity Through Alternatives to Incarceration: Building on Lessons Learned During the COVID-19 Pandemic. The Board directed staff to conduct a data-driven analysis of public safety and to identify service gaps across the delivery system. Initial findings highlighted care coordination as a challenge due to the need for a data governance structure and data sharing between programs for this population. Subsequently, on May 10, 2022 (3) the Board approved Supporting Care Coordination for Justice-Involved Individuals Through Funding and Integrated Data Infrastructure, further demonstrating the Board’s commitment to addressing inequities and health disparities that impact the justice-involved population. This action acknowledged the challenge of coordinating care across justice, health and social service sectors without a data governance structure and integrated data system. The Board directed staff to report back on the status of this ongoing project at specified intervals.
In response to the Board’s actions, staff submitted a memorandum to the Board on August 17, 2022, describing the formation of a Strategic Planning Workgroup and the project plan. A second update followed via a memorandum on December 30, 2022, which described updates to the project plan, forums in which feedback from communities was gathered, and initial assessment findings. Then on February 28, 2023 (20), staff returned to the Board with an update including a report entitled Supporting Care Coordination for Justice-Involved Individuals through Funding and Integrated Data Infrastructure: Report on Potential Opportunities and Challenges Impacting Data Sharing.
Today’s action requests the Board receive an update on Supporting Care Coordination for Justice-Involved Individuals through Funding and Integrated Data Infrastructure: Data Governance and Integration. This update outlines the benefits of care coordination use cases as a methodology to understand the needs and to identify potential solutions for data sharing and integration and provides a new data management structure to facilitate requests for data sharing to support care coordination for justice-involved individuals.
Care Coordination Use Cases
An important consideration in identifying effective use of data is understanding the existing structure of a program or process and its implications on care delivery. Care coordination use cases create a timeline and map of a client’s journey through a program and identify where decisions may be made and what information is valuable to have along the way. They are essential tools for identifying data sharing and system process improvement opportunities to enhance care coordination efforts and to elevate such requests through the data governance structure. This methodology helps to identify areas where data sharing would benefit care coordination, or, if in fact the perceived need would instead benefit from process improvement, allowing data governance and sharing to be solutions oriented and preventing assumptions from driving the request for data sharing. Instead, this methodology provides the information necessary to ensure high quality data is shared to enhance care coordination efforts and outcomes.
Three care coordination use cases developed in March 2023 demonstrate the value this methodology would add to the data governance process by illustrating the different parts of the reentry process, as well as the partners involved in coordinating an individual’s release. The ability to show a program’s different stages, from commencement to conclusion, as well as the populations it serves are critical to defining the kind of data needed to implement enhancements. The three use cases developed in March 2023 focused on the County’s Community Care Coordination (C3) and justice-involved Mental Health Diversion Programs, and the Sheriff’s Department Supporting Individual Transitions (SIT) Program.
Care Coordination Use Case 1: Community Care Coordination Program
The County’s C3 Program connects individuals exiting jail to a community-based organization to begin in-reach and care coordination prior to re-entry and mainly serves individuals at risk of homelessness and living with behavioral health or complex health needs. C3 teams are comprised of a case manager and two peers with lived experience. Referrals come from jail re-entry staff and the San Diego County Public Defender Office (PD) while the person is in custody. Other justice partners, such as the Probation Department, coordinate with the Sheriff’s Department to refer an individual to the program. This helps ensure that the C3 teams are ready to provide the needed resources when individuals leave jail. Resources may include supported housing and connections to services such as health care, mental health treatment, substance use treatment, and other supportive services identified during the comprehensive assessment of individuals. The assigned C3 team continues to support the individual's transition into the community for up to a year.
The C3 program use case found that sharing discharge documentation and release information is critical to continuing the individual's care in the community. This information would be needed at the moment of the client leaving jail. It was also identified that C3 care coordination would benefit from increasing the number of providers who have access to County Behavioral Health Services (BHS) Electronic Health Records (EHR) to understand the behavioral health needs of their clients. Currently, the provision of care is somewhat siloed in the provider's case management system and doesn't seamlessly integrate into the County's system of record.
Care Coordination Use Case 2: Justice-Involved Mental Health Diversion Program
The justice-involved Mental Health Diversion Program under Penal Code 1001.36 identifies people with serious mental illness, where there is a possible nexus between their crime and illness, who would benefit from community-based treatment rather than custody. As part of this program, a petition is filed with the court by the defense council to suspend someone’s criminal case on the condition they engage in approved mental health treatment. If the client is represented by the Public Defender (PD), the PD's Holistic Services Unit works with attorneys, other justice partners, and community-based mental health providers to identify and engage clients, refer them for mental health treatment, and prepare their cases for the Mental Health Diversion hearing. If the court accepts the person can be successful in the community while in treatment, the petition is granted, and the client is referred to a behavioral health provider. The community provider in receipt of the referral is responsible for providing client progress reports to the court and the client is responsible for maintaining engagement in the program. If the client is determined to be successful at meeting the treatment plan goals as laid out by the behavioral health provider the court dismisses their case.
The Mental Health Diversion program starts with identifying clients who may be eligible. The work to develop a mental health diversion petition is labor intensive based on the crime of which an individual is accused and an assessment of their mental health, as is coordinating post-release care ahead of the mental health diversion petition being approved. Once approved, an improved data sharing would enhance the transition of care by allowing for clearer communication on client needs to community care providers. The court must determine, after up to two years, whether someone is successful, which makes timely and uniform status reports a key piece that could determine someone's success. However, treatment status reports may contain varying information or details about a client’s engagement in care, and providers do not all have a uniform process for sharing information back via status reports. Additionally, care providers from community-based organizations work in different case management systems, resulting in care coordination history being lost, as in most cases, this information is not transferred to the County.
Care Coordination Use Case 3: Supporting Individual Transitions
The Sheriff’s SIT Program engages individuals while they are in custody, focusing on those who frequently re-enter jail. The SIT team works with this population while in custody to establish connections to services when they exit. The program develops a cohort of the 100 people with the highest rates of return to jail in the previous three years, then wraps services around their needs while in custody and creates an ongoing case plan as individuals enter and exit custody. This ensures that case planning can start as soon as the individual enters jail including connecting them to community programs, where possible, so that even individuals with a short length of stay may be connected to services.
The SIT staff develop an individualized case plan for each client who is identified as one of the 100 people most often entering the jail. The plan is then adapted over the next two years as the client enters and exits the jail. SIT staff access information from several justice data sources to find information on clients but have limited visibility into the community programs each individual is engaged in. This makes arranging services difficult given short stays in jail. Like C3, the SIT staff would benefit from more of their providers having access to County BHS EHR. Further, the SIT staff have limited access to housing resources to ensure people can effectively be connected to housing at discharge, despite housing being a consistent need of SIT clients. One opportunity to address this need is the Sheriff’s Interim Housing (IH) and IH transportation services program, which provides individuals leaving custody with short-term housing assistance upon release. However, exploring opportunities to share information with other community-based housing options may also assist with timelier placement into housing upon release from jail.
While an integrated data infrastructure will allow for creating a longitudinal view across the care continuum, there may be solutions that meet other needs of programs that serve justice-involved individuals. Utilization of care coordination use cases supports the identification of new and improved efficiencies for care coordinators. Additionally, care coordination use cases may be developed to support coordination of care through data sharing for strategic planning, operations, or program evaluation. Future use cases will not necessarily be limited to County data and may involve community data as well.
Data Governance Structure Framework
In the report submitted to the Board on February 28, 2023 (20), data governance was defined as the set of standards and procedures for managing data through all levels of the data life cycle, including collection, storage, retention, security, privacy, access controls, analysis, reporting, integration, compliance with applicable laws, and both internal and external policy oversight. The proposed data governance structure for care coordination of justice-involved individuals adheres to a set of information sharing principles, guides information sharing both outside and within County Business Groups (Groups) - HHSA, Public Safety Group (PSG), Land Use and Environment Group, Finance and General Government Group - and their respective departments and provides space for community engagement. County staff have identified priority tasks and next steps for implementing the proposed data governance structure, including a six-month pilot to test the structure with use cases.
Guiding Principles for Information Sharing
The proposed data governance structure for care coordination of justice-involved individuals will result in improved information sharing for a person-centered delivery of services, and thus, better health and well-being outcomes, and:
• Does no harm and ensures a client-centered emphasis on data sharing which incorporates public stakeholder insight, expertise, and experience;
• Focuses on problem-solving to reduce barriers to care coordination and enhance quality of care;
• Resolves data needs at the level of operation closest to those involved in the work, when possible;
• Is based on a standardized structure of data to meet most needs with minimal review required, while adhering to privacy, data sharing, and data security standards and regulations, and upholding data integrity and quality; and
• Is supported by County executive leadership, Groups, and departmental data governance, allowing for alignment, coordination, and collaboration.
The proposed data governance framework will transfer these principles into a pathway for sharing data more often and more efficiently in a manner that addresses the concerns of County and community stakeholders. To effectively serve its core functions, the framework consists of five primary structural components:
1) County Business Groups Data Governance
To keep data sharing solutions as close to the operational and care management teams as possible, data governance will start with the Group where the program resides. Each Group has existing data governance structures that can be utilized to address data sharing for care coordination. This also ensures that the subject matter experts, data stewards, and compliance teams are consulted and brought into the process early. Requests for data sharing that do not involve sources from other Groups will be handled within its respective data governance structure.
2) Cross-County Data Governance Team
When a request involves multiple Groups, it will be elevated to the Cross-County Data Governance Team. This team will consist of community members, including individuals with lived experience, and County staff representing each Group’s data governance across the County enterprise. The Cross-County Data Governance Team will have three core responsibilities: 1) strategic planning; 2) guiding processes for ensuring care coordination and operational excellence; and 3) developing guidelines for monitoring, evaluation, and interpretation in collaboration with the Office of Evaluation, Performance, and Analytics. As part of its three core responsibilities, this team will address the opportunities for data sharing described in the February 28, 2023 (20) action, categorizing them into short-term, mid-term, and long-term goals. The team will also be responsible for guiding the creation and maintenance of a dataset that meets the needs of most data requests. This will allow requestors to select from a menu of legally available data to meet their needs and require less time for review because the data has already gone through a quality assurance and approval for sharing process.
3) Subject Matter Expertise in the areas of Legal, Compliance, and Information Technology
The Cross-County Data Governance Team will consult with County Counsel, Office of Ethics and Compliance (OEC), HHSA Compliance Office, and information technology (IT) subject matter experts (SME) when appropriate. The team will consult these groups throughout the process of fulfilling data requests and creating standardized datasets. County Counsel, OEC, and HHSA Compliance staff will provide crucial navigation of standard requirements, laws, and regulations related to data sharing. The team will consult IT SMEs from the County Technology Office, HHSA, PSG, and others as appropriate to establish the technology infrastructure needed to share data cross-County and with community stakeholders.
4) County Executive Leadership Steering Committee
Many data sharing agreements within the County are currently approved at the department level. As such, the processes among departments vary. The creation of a County Executive Leadership Steering Committee would allow County leadership to focus efforts on setting priorities and providing guidance to the Cross-County Data Governance Team. With this proposed data governance structure, the Cross-County Data Governance Team would be able to approve most data requests and solve problems before consulting with leadership.
5) Community Engagement Opportunities
In alignment with the May 10, 2022 (3) Board action, which requested that the proposed data governance structure includes community members to guide data analysis and interpretation while working with stakeholders and SME, the proposed structure includes numerous opportunities for community members, including those with lived experience, to develop and analyze use cases in a standardized way. Community insight, experience, and expertise will be of great value to Groups’ Data Governance and the Cross-County Data Governance Team. The County will create opportunities to educate about the data governance structure and seek feedback from stakeholders and community providers on barriers to, and goals of, the data governance and data sharing process for care coordination of justice-involved individuals. Another important activity will be to share care coordination best practices and explore opportunities to build on those successes.
Priorities and Next Steps for Establishing a Data Governance Structure
The vision for the data governance structure is to implement a rules-based approach to sharing information for care coordination to reduce barriers and increase the efficacy of programs that serve justice-involved individuals. County staff will prioritize programs or practices which engage with justice-involved individuals across the criminal justice system and in the community that could benefit from improved data sharing while ensuring the guidance of technical and legal expertise in the process. The following priorities will be employed as part of establishing a data governance structure:
• Community Engagement: Partnering with our communities through a transparent and solutions-based process creates opportunities to address data sharing needs.
• Establish Definitions for Common Terms: Establishing definitions for common terms is critical in ensuring a common understanding when discussing data.
• Utilize Care Coordination Use Cases: Developing and analyzing use cases to identify areas where data sharing will enhance care coordination is foundational to the data governance process.
• Engage and Enable Data Stewards: Engaging and enabling data stewards throughout the County and community to achieve the goals of data sharing to improve and facilitate care coordination.
These priorities drive the next steps in establishing the proposed data governance structure. A six-month pilot will be conducted which will allow time to test and refine the proposed structure. Care coordination use cases will be developed and elevated through the structure as appropriate. The objectives of the pilot are:
• Determine the scope of the data governance structure and how it engages with data stewards and community members;
• Identify the engagement and decision-making process; and
• Identify the steps to develop a data catalog that would meet most data sharing requests.
Included as part of the objective to identify the engagement and decision-making process, a standardized data request process will be developed to improve the customer experience when requesting data. If requests fall outside the scope of this data governance structure, it will still be routed to the appropriate Group. Additionally, ensuring adherence to privacy, data sharing, and data security standards and regulations will be an essential part of this objective, including utilization of best practices such as data use and data sharing agreements to specify what data can be shared, and how data may be used and protected. To successfully identify the steps to develop a data catalog that would meet most data sharing requests, the Cross-County Data Governance Team will identify a limited set of data needed to outline a justice-involved individual’s journey through specific County systems such as jail, court, mental health, and substance use disorder treatment. The dataset will serve as a proof of concept to ensure the data is valuable for care coordination as well as provide the information necessary for building out the infrastructure for maintaining and expanding this type of analysis going forward. Upon approval of today's action, it is anticipated the pilot will begin July 1, 2023.
Additionally, a resource assessment plan will be developed and implemented to engage with County departments to assess the resources required to prepare current data systems for future data integration needs. The County Data Infrastructure Assessment, described in the February 28, 2023 (20) action, highlighted that many departments across the County enterprise would benefit from additional resources related to staff and technology to prepare the systems that capture information on justice-involved individuals and support data integration efforts.
Today’s action requests the Board amend the report back schedule as described in the May 10, 2022 (3) action to eliminate the requirement of every 180 days and replace it with a report back in early 2024. It is anticipated that findings from the pilot and the resource assessment will be included as part of the report.
California Advancing and Innovating Medi-Cal and Data Integration Opportunities
As part of these collaborative efforts, the County consistently seeks funding opportunities to help bolster care coordination efforts for justice-involved individuals. Under California Advancing and Innovating Medi-Cal, Providing Access and Transforming Health (PATH) is a five-year funding strategy to build the capacity and infrastructure of involved partners, such as community-based organizations, public hospitals, county agencies, tribes, and others, to successfully participate in the Medi-Cal delivery system. One component of PATH is the Justice Involved Capacity Building (PATH JI), a funding source to support implementation of the pre-release enrollment processes as well as pre-release and re-entry services.
In August 2022, the County was awarded $250,000 through the first round of PATH JI to prepare for the implementation of the pre-release Medi-Cal enrollment process. In March 2023, the County applied for $5.75 million during the second round of PATH JI. If awarded, the funding will be used to implement an enhanced process for individuals preparing to leave jail to enroll in Medi-Cal. Funding would support information technology modifications and staffing for the County HHSA, Sheriff’s Department, and Probation Department. Future rounds of PATH JI funding could support the development and implementation of pre-release and re-entry planning services in the 90 days prior to an individual’s release, which the County also intends to apply for upon the release of the applications.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s actions support the County of San Diego’s 2023-2028 Strategic Plan Initiatives of Equity (Health), Empower (Workforce, Innovation), and Community (Engagement, Quality of Life, Partnership). Supporting care coordination for justice-involved individuals creates a structure that will reduce the burden on individuals as they try to navigate complex health and social care systems and enhance providers’ abilities to connect clients to services.
Respectfully submitted,
HELEN N. ROBBINS-MEYER
Interim Chief Administrative Officer
ATTACHMENT(S)
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