Coordinated health and human services delivery system and process

Abstract

A system (200) and method (500) is provided for a coordinated health care service delivery program. The method can include providing services to clients at high risk for chronic disease including co-morbidities and consequent disabilities associated with the chronic disease, linking community and vocational services (130) for facilitating community inclusion to supplement fundamental clinical and economic goals, creating a comprehensive and dynamic individual development plan (222) to involve the client and family members as active program team members for stressing client-centric collaborative goal setting, and applying action learning (226) to promote behavior modification and lifestyle change.

Description

CROSS REFERENCE TO RELATED APPLICATION [0001] This application claims benefit of U.S. Provisional Application No. 60 / 654,932, filed Feb. 23, 2005, entitled “Coordinated Health and Human Services Management Network”, by Jay E. Yourist, Karl J. Krieger, Robert L. Dilworth, and Zuhair Latif, which is hereby incorporated by reference.FIELD OF THE INVENTION [0002] The embodiments of the invention herein relate to management systems, and more particularly a method of health and human services delivery. DESCRIPTION OF THE RELATED ART [0003] The management practices of the healthcare system evolved in response to the high incidences of acute illnesses. However, over the last fifty years the prevalence of chronic illness has risen significantly. Chronic disease is a leading cause of disability and consequently unemployment for special needs populations including the elderly and disabled. Indirect non-clinical care costs frequently associated with disability, dependency, and joblessness are h...

AI Technical Summary

Benefits of technology

[0012] An object of the invention is to bring together an array of interlocking modalities and constructs in ways that are mutually reinforcing and a part of one single overarching system. Typically, individual health care system components, such as peer support teams and circles, are usually used in isolation from one another rather than in juxtaposition with other systems or components of systems. In other cases there is no known existing parallel to these system pieces; that is, the manner in which principles of action learning are to be employed. The system component involved within the context of the invention, even if similar to systems that are already available in some form in the market place, have been specifically tailored to fit within the overall coordinated human and health services and delivery system to promote synergy. A core essence of the embodiments of the invention, as well as the uniqueness, is in its broad integration of essential services as a single system. The system is designed to holistically provide the necessary support mechanisms and services to not only improve the health status of those with chronic disease and disabilities of clients, but also to improve their quality of life, build their self-efficacy and level of self-confidence, and position clients for reentry into the workforce.

[0013] Referring to FIG. 1, an illustration for a connectivity of services is shown. The illustration represents the services as pieces of a puzzle connected together by an information technology (IT) platform. The IT platform is just one embodiment demonstrating how various system pieces can be widely integrated from a process standpoint, in support of chronic disease management, social services and support for those with chronic disease and / or disabilities. Various embodiments of the invention, in addition to the IT embodiment, are herein contemplated. The IT component can be considered as a tool to facilitate service coordination and data collection and analysis for a continuum of available services. Understandably, information technology can be interwoven throughout the services and delivery system in ways that optimize the sharing of critical information, both within the specific system and with external organizations, such as Vocational Rehabilitation. As a result, a coordinated human and health services and delivery program can be established wherein case management under such a program can become much more efficient. Rather than a series of individual and isolated system components or services, the framework creates an open system for coordination of services from the standpoint of information sharing across agency and organizational lines.

[0014] The business methods underlying the system of coordinated health and human service delivery herein presented can be applied to various contexts and operations. For example, the system can be configured to target Social Security Disability Insurance (SSDI) or Social Security Insurance (SSI) beneficiaries. Understandably, these beneficiaries are unique and require a broad range of support services to sustain community integrations which the coordinated health and human service delivery of the invention is uniquely adapted to provide. The coordinated health and human service delivery herein presented is flexible and adaptable to such unique demands. In one particular example, Federal and State systems have been minimally successful in enticing such individuals to actively return to the workplace (i.e., The Ticket-To-Work program). Consequently, one aspect of the invention is configurable for addressing the complexity of this problem. The embodiment of the invention can prove highly effective in providing coordinated services to other clientele groups as well. For instance, in one aspect, the underlying business methods can be readily customized to serve the elderly or to operate in different cultures in the United states or elsewhere. The system can evolve and adapt over time due to the inherent system flexibility afforded by the uniqueness and novelty of the coordinated delivery services model.

Problems solved by technology

Chronic disease is a leading cause of disability and consequently unemployment for special needs populations including the elderly and disabled.

Chronic disease is a leading cause of disability and unemployment undermining worker productivity and employability.

Minority populations have also demonstrated a higher incidence of chronic conditions, primarily diabetes and ensuing disability, further disenfranchising those particular populations.

Historically, healthcare practices were not coordinated but episodic and fragmented thereby proving to be increasingly inefficient for treating individuals of chronic diseases.

In addition, service providers did not readily have access to client information which resulted in limited service delivery and cost inefficiency.

Healthcare expenditures have steadily increased due to unnecessary hospital admissions, expensive and indecisive technologies, and the accumulation of conflicting clinical data.

These expenditures have not provided substantive improvements in health status, community integration, or independent living.

However, despite significant efforts by the SSA to provide employment opportunities such as the “Ticket to Work Program”, less than 1% of all disability program beneficiaries return to gainful employment.

Considerable evidence and testimony from beneficiaries, advocates and providers have noted significant weaknesses in the Ticket to Work Program namely; 1) eligibility criteria exclude certain beneficiaries with significant return to work potential, 2) conflicts exist between the vocational rehabilitation system and the Ticket Program, and 3) the provider payment system has failed to recruit sufficient providers to guarantee beneficiary choice in job training and supports.

Consequently, overwhelming use of State VR agencies and the low numbers of ENs assisting current “Ticket” holders indicate that the goals of the Ticket Program to enhance access to services, primarily employment, are not being met.

The programs consume approximately five percent of the federal budget, and are projected to become much more costly through 2012.

This has met with limited success and the suggested reforms and barrier removal strategies to improve the delivery of the Ticket Program tend to focus on policy changes and administrative systems in isolation, rather than following a holistic, integrative or a total systems approach.

However, the traditional health care programs have been fragmented and ineffective.

They were not successful due in large part to the practical inability to access and share medical data.

A major barrier to providing such services was also conflicting business interests, namely the reluctance for multiple healthcare providers to cooperate and coordinate their services due to increased competition.

The dissociation has compounded the problem to the detriment of both healthcare and economic remedies.

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