Health system takes an 'Epic first' approach to integrating all data, including SDOH

Contra Costa Health Services takes on whole person care by gathering every bit of data, not just medical care data, and getting it into its Epic EHR. The results have been startling.
By Bill Siwicki
03:48 PM

Contra Costa County Regional Medical Center in Martinez, California.

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.

"Reducing the amount of manual work related to enrollment has not only made the program more scalable, but also freed up resources to reallocate to direct client services and case management. In fact, the WPC program estimates that automating the work required to determine a client’s eligibility and enroll them in the pilot has saved nearly 350 administrative hours per month."

Sue Crosby, Contra Costa Health Services

“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.

All care team members have access

Some data from these systems are shared directly in the EHR through the patient chart, allowing all care team members access. Other information is used in the background by program managers for patient stratification by risk scores, predictive analytics for strategic planning, and reporting. New data sources have allowed the county to refine its ability to appropriately assign and serve patients.

“The value of this data connection was recognized in the story of Amy, a 31-year-old mother of two who identified as a high-risk individual in the WPC risk model through past utilization of 10 emergency department visits, three psychiatric emergency department visits and clinical documentation indicating previous substance use history and a bipolar diagnosis,” Crosby explained. “Amy was automatically enrolled in the program and assigned to a Substance Use Case manager based on her past history.”

The case manager was notified of her new patient through her interactive Caseload Management Dashboard and reached out to Amy to begin screening for active social needs. Together they prioritized the area of connecting to Mental Health services as Amy disclosed she’d been feeling depressed, had recently stopped taking her prescribed medications, and was self-medicating with other substances, she said.

“Amy and the case manager called the County Behavioral Health Access Line together to schedule an appointment to see a licensed therapist to support her depression needs,” she said.

A housing situation had changed

Amy developed a positive relationship with her therapist and began taking her behavioral health medications again. During one session, Amy disclosed to the therapist that her fragile housing situation had changed, and she was now spending many nights sleeping in her car with her two daughters.

“Recognizing the seriousness of this situation with two small children involved, the therapist let Amy know that she was going to reach out to her case manager to work together,” Crosby said. “The therapist was able to quickly find the case manager’s phone number in the shared care team in Epic and contacted the case manager to alert her to the situation.”

The case manager was able to get Amy and her daughters placed in housing quickly after a short stay at a family shelter. A year later, Amy has since graduated from the program, remains housed in her apartment, has stabilized her medications, and is employed again.

“In talking with Amy about her experience, she felt that the most beneficial element of her involvement in the WPC program was the relationship she developed with her case manager,” Crosby related. “Amy said that she felt like someone truly cared about her and that she was worth their time, a feeling she said she hadn’t felt in a long time.”

Automatically identifying frequent users of multiple systems

On another front, one of the biggest successes of the program is the establishment of an automated, scalable system for identifying clients who are frequent users of multiple systems and assigning them to personalized services. The system depends entirely on the availability of robust and accessible data.

“Reducing the amount of manual work related to enrollment has not only made the program more scalable, but also freed up resources to reallocate to direct client services and case management,” Crosby said. “In fact, the WPC program estimates that automating the work required to determine a client’s eligibility and enroll them in the pilot has saved nearly 350 administrative hours per month.”

Regarding the behavioral health rollout, within just one week of behavioral health providers starting to document in the EHR, providers reported benefits of having access to that new information in the shared EHR.

“For example, the psychiatric emergency department and the inpatient psychiatric unit were now able, for the first time, to easily view information on care coordination and referrals from their partners on the ambulatory side of the mental health department,” Crosby stated.

Focusing on process improvement

Having a clearer, fuller picture of mental health services available in the shared EHR allows the county to focus on process improvement. For example, they can now monitor how patients are referred to services through the Behavioral Health Access Line, the county’s first gateway to seeing a behavioral health provider, and how long it takes to go from screening to referral.

That information can now be shared across the system to aid in more real-time assessments and process improvements in staffing and scheduling.

On the integrating housing information front, Contra Costa County has about 3,000 persons experiencing homelessness on any given day. About 250 programs at organizations throughout the county serve about 9,000 people a year and enter service and program information into a Homelessness Management Information System.

“There was previously no way to share that information with providers of other disciplines, or to receive information about who else might be working with those homeless clients,” Crosby said.

Better sharing data with the data warehouse

One of Contra Costa’s goals through WPC was to transition to an HMIS system that could better share information with their data warehouse and the EHR.

“The Whole Person Care program implemented a new HMIS in 2017 that is now fully integrated with the data warehouse,” Crosby explained. “Since the program uses a universal consent form across all county services, these newly integrated data are accessible to the health services department, including case managers and social workers in both clinical settings and community based organizations.”

The data warehouse now includes data on whether an individual has accessed any homeless program in the past 15 years and a measure that indicates whether that person is currently homeless. In the future, HMIS data available in the EHR will include housing programs the patient is actively engaged with, as well as contact information.

Data from the EHR that flow into the HMIS include the name and contact information of case managers for three different case management programs. In addition, data from the HMIS shared via the county’s data warehouse serve as valuable inputs to the predictive risk algorithms used for program enrollment and case manager assignment.

From manual tracking to automatic

“A query to the HMIS data in the data warehouse identifies new homeless individuals and pulls their information into a report that housing providers can access through a web-based portal,” Crosby said. “Rather than tracking housing priority manually for more than 700 new clients a month, they are now able to identify the most vulnerable clients, match them to appropriate levels of supportive housing, and more accurately and efficiently assign housing resources across the entire county.”

Restoring Medicaid coverage

And through its efforts, Contra Costa Health Services is restoring Medicaid coverage for lapsed patients. Contra Costa developed a process to reach out to individuals whose Medicaid has lapsed, and have been able to restore coverage for nearly 40% of eligible patients, with a projected savings of nearly $2 million for the Medicaid health plan.

Building on this with a new partnership with the county social services department, they developed a prospective workflow to identify patients earlier in the Medicaid redetermination process to improve retention. In the first two months of the pilot, they’ve brought the rate of lapsed coverages down from 23% to 10% and are working to fully integrate this information into Epic.


Healthcare provider organizations interested in conducting some of the same efforts Contra Costa Health Services has conducted must understand the long-term vision for technology across their organizations, Crosby advised.

“At Contra Costa Health Services, it was to become more integrated using a single shared health record and centralized data warehouse,” she said. “Information technology has been a key driver in aligning disparate divisions and a commitment to use ‘Epic first’ has been established to maximize the investment.”

Also, compromise may be required to achieve the organization’s larger goals of integration, she added.

“Technology solutions developed for niche areas – case management, risk models – are often promised as ‘out of the box’ and may be ideal for the project at hand, but do not contribute to a larger goal of integration and sustainability,” she stated. “It is important to be able to justify decisions on systems to use to leaders and end users. However, it’s important to justify the cost and demonstrate ROI. Don’t try to make a square peg fit in a round hole if it’s not worth it.”

Healthcare organizations also should challenge the status quo of what should be included in the electronic health record, Crosby advised.

“As the healthcare industry is rapidly evolving to incorporate social determinants of health into the traditional understanding of healthcare, health IT strategy should evolve with this to support incorporating social determinants of health and care management into the traditional EHR. There can be great value provided from including information such as insurance coverage, housing interventions, food insecurity, etc., in delivering better and more integrated care to patients.”

Twitter: @SiwickiHealthIT
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