Services for the UnderServed (SUS) is a New York City-based nonprofit organization that provides $185 million in services to individuals with disabilities, people living in poverty and those facing homelessness. The organization, which has a staff of close to 2,000, needed a way to track measurable results for people with behavioral issues, so it adopted a health information technology (HIT) platform.
HIT platforms make it much easier for health care organizations to gather and report results of value-based care delivery to governmental organizations and foundations. Proven success rates can also pave the way to get program funding.
SUS was given a program grant by the Department of Health to decrease challenging behavior and restrictive residential living for people with behavioral issues. The grant period was set for two years and followed the progress of 30 individuals.
SUS needed an HIT platform that could work with the level of detail required to track that group. Vivian Attanasio, vice president of behavioral services for SUS, says that Virtual Health was recommended by two senior staff members who had seen a presentation of this population health management platform.
Her team was able to get the program running in just six to eight weeks. That fast-tracked ability was essential because SUS was notified of the grant award a couple of months into the two-year period. That forced the organization to do some backtracking on the records, but it was able to catch up and upload all the data.
The data tracked for those receiving behavioral services includes behavior, appointments, medications, hospitalizations, life skills developments, and movement from more restrictive to less restrictive environments that allows the individuals to be a part of the larger community.
Data was uploaded monthly to Virtual Health’s platform, which enabled SUS to create visualizations, see trends, and produce graphs according to the specified domain and date range. The program could even track the history of a single individual to identify any outliers—as in the case of a woman with multiple health problems that required regular hospitalization—which could be graphed separately from the overall group.
The staff was then able to easily see the results for program evaluation and to prepare visual aids for presentations.
Data Tracking Demonstrates Achievements
Tracking the data showed SUS’s accomplishments with the 30 members of the group in quantifiable terms. It achieved a 15 percent reduction for caregivers across the board—a saving its CEO could factor into planning for long-term staffing. The organization also reduced challenging behavior by 70 percent within the first six months and achieved a 30 percent reduction in the use of psychotropic drugs by the end of the grant period.
These accomplishments were made possible by having a comprehensive view of patient care, which includes both physical and mental health factors. The SUS staff looks at emergency room visits and hospital admissions to determine if they were preventable, and whether they involved medical or behavioral issues. Any health indicators, such as changes in weight or diagnosed conditions like diabetes or hypertension, are also noted.
A prime consideration in the grant study was determining whether the 30 individuals were achieving greater independence. Accordingly, SUS tracked changes in living conditions, noting when individuals moved from locked wards to less restrictive environments—or even participated in a community by managing their own residence, navigating transportation, interacting at stores, etc.
To be able to decrease medication, the types and dosages prescribed were tracked. To enable a reduction in the staff-to-patient ratio, the data had to show a decrease in the number of necessary staff interventions.
Maintaining Differentiated Access and Confidentiality
Attanasio reports that the system was very intuitive and easy to learn, a big benefit when multiple people have to use it. She adds that the staff members were given different levels of access. Some could input data but not make changes—something only those managing the grant program could do.
When an outside consultant reporting to the Department of Health came in with a computer that was not HIPPA-compliant, all data transferred to that computer had to have all personally identified information removed. Within a couple of weeks, Virtual Health worked it out so that the consultant could see only client ID numbers, while SUS retained the names coupled with those IDs.
SUS intends to capitalize on that type of customized view and protected access by getting Virtual Health’s help with its participation in New York Start, a program that offers crisis prevention and response services to people with intellectual and developmental disabilities. SUS will be cooperating with other state agencies, and the Virtual Health program will allow it to manage access given to team leaders at those agencies.