Sharing data about vulnerable clients between service sectors: Is the juice worth the squeeze?

Many residents of San Francisco face multiple challenges from mental and physical health impairments, addictions, and homelessness. While the City offers a rich array of services to address clients' needs, care for high users of emergency or urgent services can be fragmented and uncoordinated. Providers often do not know if a client is receiving services from others, as databases within systems do not exchange information and there is no a universal client identifier.

The Coordinated Care Management System (CCMS) is a data warehouse that began development in 2005 to facilitate communication regarding shared vulnerable clients across multiple system of care. The common patient trait was having serious health and social needs and using multiple care systems, The initial clients were high users of ambulance services and/or were homeless and frail elderly SF residents. Today, CCMS has grown to include bio-psycho-social histories of over 300,000 patients who have used the city's safety net or urgent/emergent services over the past 10-20 years.

By combining data from over 11 different sectors (including housing, shelters, medical, mental health, substance abuse, psychiatric and medical emergency, ambulance transport, the death registry, and others), CCMS presents providers and the health care system with a full picture of the lives of our most vulnerable clients.

CCMS contains an enormous amount of data relating to the service utilization and diagnostic conditions of high users of emergency and urgent care services. This presentation will discuss the creation and working of the CCMS and present data about the clients served.