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.

1 ) A business method of coordinated health and human services and delivery comprising: 
 providing services to clients at high risk for chronic disease including co-morbidities and consequent disabilities associated with said chronic disease;    linking community and vocational services for facilitating community inclusion to supplement fundamental clinical and economic goals;    creating a comprehensive and dynamic individual development plan to involve said client and family members as active program team members for stressing client-centric collaborative goal setting; and    applying action learning to promote behavior modification and lifestyle change.    
     
     
         2 ) The business method of  claim 1 , wherein said providing services includes 
 delivering culturally-relevant services customized for minority, underserved, and underinsured communities having particular demographic requirements.    
     
     
         3 ) The business method of  claim 1 , wherein said linking includes 
 focusing on reach-out goals of improved quality of life of said clients by encompassing clinical, social, and vocational measures and outcomes; and    integrating a comprehensive set of healthcare, vocational, community integration and education services.    
     
     
         4 ) The business method of  claim 1 , further comprising 
 coordinating and maintaining connectivity of said services and overall communication among program stakeholders; and    providing tools and suitable media for customized data collection and capture, analysis, archiving, communication and information sharing of said services and communication.    
     
     
         5 ) The business method of  claim 4 , further comprising: 
 measuring and analyzing outcomes of said services and said individual development plan by monitoring indicators and metrics for providing continuous quality improvement measures; and    validating said services and said individual development plan premises in view of said data measuring and analyzing.    
     
     
         6 ) The business method of  claim 5 , further comprising combining data analysis results of said services and said individual development plan for developing new cost economic models.  
     
     
         7 ) The business method of  claim 1 , wherein said linking further includes linking local, state, and federal systems for providing seamless delivery of services.  
     
     
         8 ) The business method of  claim 1 , further comprising placing peer support teams at the core of a service delivery model for providing a coordinated management architecture.  
     
     
         9 ) The business method of  claim 8 , further comprising providing a peer support system that empowers said client through customized self management education and problem solving skills to improve a health, community integration, employment readiness, financial well being and overall quality of life of said client.  
     
     
         10 ) The business method of  claim 1 , further comprising 
 promoting personal accountability through the development of an Individual Development Plan (IDP) and self management education; and    utilizing action learning and peer support team principles to promote self determination, advocacy, gainful employment, and independence.    
     
     
         11 ) The business method of  claim 10 , wherein said action learning empowers clients to solve problems with peers and case managers, said problems associated with a clients' health management service and reimbursement policies.  
     
     
         12 ) The business method of  claim 10 , further comprising developing and implementing said coordinated health care delivery and services in phases consisting of primary and secondary intervention strategies, wherein a Primary intervention is based on an individual development plan, and a secondary intervention is based on a service system including at least one of clinical, educational, community, vocational services and benefit counseling.  
     
     
         13 ) The business method of  claim 10 , further comprising imposing evaluative mechanisms for streamlining accountability of said coordinated health care services and delivery program for the individual participant and for the coordinated health care system in an entirety, wherein said evaluative mechanisms include at least one from the group comprising: efficacy of recruitment, attainment of IDP goals, clinical goals outcome, job readiness and actual placements, assessment of participant satisfaction, and quality of life measures.  
     
     
         14 ) A coordinated service delivery program for coordinated health and human services management comprising: 
 an intake assessment and recruitment module for population stratification and recruitment for clients having chronic disease or disability;    a primary intervention module for developing an individual development plan and for enacting action-learning through peer support team intervention;    a secondary intervention module for providing coordination of services; and    an information archive to coordinate services for monitoring and tracking client progress;    wherein the coordinated service delivery system is a population-based, client-centric strategy that combines self-management skills with said services to facilitate functional and psychosocial needs of the client for focusing on community integration and re-employment.    
     
     
         15 ) The coordinated service delivery program of  claim 14 , further comprising 
 a program evaluation module for evaluating performance indicators against external indicators from a control group; and    a policy recommendations module to review findings in view of said performance indicators and to make recommendations based on performance results from said coordinated service delivery program.    
     
     
         16 ) The coordinated service delivery program of  claim 15 , wherein the program evaluation module further provides individualized outcomes studies for developing outcome health care studies for evidence-based healthcare programs.  
     
     
         17 ) The coordinated service delivery program of  claim 14 , wherein the evaluation module analyzes and measures an effectiveness of the coordinated service delivery program.  
     
     
         18 ). The coordinated service delivery program of  claim 14 , wherein the program evaluation module standardizes said delivery program on clinical, social, behavioral, and economic indicators to measure and analyze overall program and individual client performance.  
     
     
         19 ) The coordinated service delivery program of  claim 14 , wherein the intake assessment and recruitment module further comprises 
 collecting long term clinical, behavior, and compliance information to evaluate long term study outcomes; and    developing a profile of client qualification criteria for recruiting clients approved with the support of all program stakeholders.    
     
     
         20 ) The coordinated service delivery program of  claim 14 , wherein the intake assessment and recruitment module further comprises: 
 entering the analysis of pre-screened clients into a program database;    interviewing the pre-screened clients for directly assessing their needs and interest in participation of said service delivery program;    selecting qualified clients, enrolling clients in an orientation program, and assigning clients to a peer support team;    updating the program database for qualified and unqualified clients;    measuring baselines such as clinical history, or quality of life survey; and    creating an individual development plan (IDP) for a client together with family members, peers, and other program stakeholders of the peer support team.    
     
     
         21 ) The coordinated service delivery program of  claim 14 , wherein the intake assessment and recruitment module further comprises analyzing at least one of demographic, employment history, prevalence of chronic disease, other health factors, utilization and other risk stratification factors for chronic disease and disability.  
     
     
         22 ) The coordinated service delivery program of  claim 14 , wherein the IDP of the primary services intervention is a multifaceted document which provides the clinical background and life history of the client including at least one of education, training received, family information, and employment history.  
     
     
         23 ) The coordinated service delivery program of  claim 14 , wherein the IDP further includes at least one of demographic information, health status information, community information, social services information, vocational information, and employment information.  
     
     
         24 ) The coordinated service delivery program of  claim 14 , wherein the services include: 
 a clinical services domain for monitoring chronic disease indicators captured during peer support team meetings that are archived in a database for complying with the IDP;    an education services domain for providing preventative education for family members of clients with chronic disease and disability;    a community services domain for supporting active daily living of clients for overcoming employment and community integration barriers; and    a vocational services domain to facilitate a coordinated continuum of services for providing gainful employment opportunities.    
     
     
         25 ) The coordinated service delivery program of  claim 14 , wherein said information archive provides real time and secure access to program information.  
     
     
         26 ) The coordinated service delivery program of  claim 24 , wherein said clinical services domain includes at least one of risk stratification, compliance monitoring, wellness/fitness programs, prescription drug and counseling programs, nutritional and supplemental programs, home healthcare encounters, outpatient primary care encounters, and inpatient encounters.  
     
     
         27 ) The coordinated service delivery program of  claim 24 , wherein said education services domain includes at least one of self-management education, advocacy training, continuing education training, micro-computer training, and technical assistance.  
     
     
         28 ) The coordinated service delivery program of  claim 24 , wherein said community services domain includes at least one of housing services, transportation services, accessibility services, adaptive technology services, and recreation services.  
     
     
         29 ) The coordinated service delivery program of  claim 24 , wherein said vocational services includes at least one of job readiness training, mentorship and internship programs, networking development, resume and interviewing skill development, and job listings and postings.  
     
     
         30 ) The coordinated service delivery program of  claim 14 , wherein said information archive is monitored on-line by one of a Support Service Manager and a PST coach.  
     
     
         31 ) The coordinated service delivery program of  claim 14 , wherein the program evaluation module further comprises assessing employment indicators including at least one of hours worked, job retention, informed choice, control, satisfaction, level and nature of required supports, and employer satisfaction.  
     
     
         32 ) The coordinated service delivery program of  claim 14 , wherein the delivery processes module guides the client through program phases to build their capability to live a full life and find meaningful employment through said Action Learning.  
     
     
         33 ) A method for coordinated health and human services delivery comprising: 
 assessing and recruiting clients and developing a team of professionals and third party providers;    developing an individual development plan for said clients;    supporting service groups and managing services for clients through action-learning and Peer Support Team Intervention; and    sharing and archiving information for consolidating data from said services and for monitoring and tracking client progress.    
     
     
         34 ) The computer implemented method of  claim 33 , further comprising 
 delivering said services for providing access to a multi-disciplinary team of experts; and    analyzing and measuring the effectiveness of a coordinated service delivery program to provide healthcare, community integration, and employment services to a client.    wherein the delivery is a population-based, client-centric strategy that combines self-management skills with coordinated services to facilitate functional and psychosocial needs of said client for focusing on community integration and re-employment.    
     
     
         35 ) The method of  claim 33 , further comprising standardizing said delivery on clinical, social, behavioral, and economic indicators to measure and analyze overall program and individual client performance.  
     
     
         36 ) The method of  claim 35 , further comprising recommending policies and guidelines based on said performance.  
     
     
         37 ) The method of  claim 33 , wherein the assessing and recruiting clients further comprises: 
 collecting long term clinical, behavior, and compliance information to evaluate long term study outcomes, and    developing a profile of client qualification criteria for recruiting a client with the support of all Program stakeholders.    
     
     
         38 ) The method of  claim 33 , wherein the assessing and recruiting clients further comprises: 
 entering the analysis of pre-screened clients into a program database;    interviewing one or more pre-screened clients in person where they live for directly assessing their needs and interest in participation of the program;    selecting one or more qualified clients, enrolling said qualified clients in an orientation program, and assigning said clients to a Peer Support Team;    updating said program database for qualified and unqualified clients; and    measuring baselines and creating an Individual Development Plan (IDP) in concert with family members, peers, and other Program stakeholder of the Peer Support Team.    
     
     
         39 ) The method of  claim 33 , wherein the developing an IDP further comprises: 
 capturing employment information from vocational assessments, resumes, internship, and mentorship opportunities, job postings, and job retention data; and    analyzing demographic, employment history, prevalence of chronic disease and other health factors, utilization and other risk stratification factors for chronic disease and disability.    
     
     
         40 ) The method of  claim 33 , wherein supporting service groups and managing services further includes developing a team for working in an environment of Action Learning to maximize a capacity and ability to collaborate with the client.  
     
     
         41 ) The method of  claim 33 , wherein supporting service groups and managing services further includes: 
 providing access to clinical, educational, vocational, and community services for placing the client in a supportive, nurturing and learning environment;    providing said services and resource coordination of services through action-learning by linking said community services, vocational services, educational services, and clinical services to promote employment outcomes; and    monitoring and tracking client progress to facilitate a coordinated continuum of services for ensuing gainful employment opportunities.    
     
     
         42 ) The method of  claim 33 , wherein supporting service groups and managing services for clinical services further includes providing at least one of risk stratification, compliance monitoring, wellness/fitness programs, prescription drug and counseling programs, nutritional and supplement programs, home healthcare encounters, outpatient primary care encounters, and inpatient encounters for monitoring chronic disease indicators captured during peer support team meetings that are archived in compliance with an IDP.  
     
     
         43 ) The method of  claim 33 , wherein supporting service groups and managing services for educational services further includes providing at least one of self-management education, advocacy training, and continuing education and training for providing preventative education for family members of clients with chronic disease and disability.  
     
     
         44 ) The method of  claim 33 , wherein supporting service groups and managing services for community services further includes providing at least one of housing services, transportation services, accessibility services, adaptive technology services, and recreation services for supporting active daily living of clients to overcome employment and community integration barriers.  
     
     
         45 ) The method of  claim 33 , wherein supporting service groups and managing services for vocational services further includes providing at least one of Job Readiness Training, Mentorship/internship Programs, Networking Development, Resume and Interviewing Skill Development, and job listings & postings.  
     
     
         46 ) The method of  claim 33 , wherein analyzing and measuring the effectiveness of a coordinated service delivery program further includes: 
 providing secure interactive communication and access to program information;    consolidating data from various information sources;    presenting said data to clients in a seamless manner; and    reporting outcomes of said health care delivery program.    
     
     
         47 ) The method of  claim 33 , wherein analyzing and measuring the effectiveness of a coordinated service delivery program further includes collecting and archiving clinical encounters or clinical indicator information captured from client diaries and PST clinical data collection for analysis.  
     
     
         48 ) The method of  claim 33 , wherein supporting service groups and managing services provides an administrative focus using a Support Service Coordination Group (SSCG) Task Team by: 
 assigning at least one Support Service Group Coordinator;    assigning at least three Learning Coaches;    assigning at least nine PSTs; and    assigning at least one Hybrid Action Learning Team.    
     
     
         49 ) The method of  claim 33 , wherein supporting service groups and managing services provides an administrative focus using at least one of a Peer Support Team (PST) Task Team, a Learning Coach, and a Peer Support Circle.  
     
     
         50 ) The method of  claim 33 , wherein supporting service groups and managing services provides an administrative focus using a Peer Support Circle Action Learning Team.  
     
     
         51 ) The method of  claim 33 , wherein supporting service groups and managing services provides an administrative focus using a Hybrid Action Learning Team by assigning at least One Action Learning Team.  
     
     
         52 ) The method of  claim 33 , wherein supporting service groups and managing services provides an administrative focus using an Advisory Council Task Team.  
     
     
         53 ) A method of providing coordinated healthcare to promote community integration and employment for persons with disabilities comprising: 
 providing active recruitment of eligible participants;    providing a support service coordination system that is consumer-driven using a peer supported Action Learning approach to coordinate, advocate and manage services; and    providing a comprehensive and coordinated network of support services through an integrated service network.    
     
     
         54 ) The method of  claim 53  further comprising: 
 providing a peer supported process of Action Learning of interactive problem solving to improve long term “Lifestyle” changes and promote consumer empowerment; and    providing consumer incentives and benefits for clients to promote and sustain long term behavior changes;    
     
     
         55 ) The method of  claim 53  further comprising: 
 providing partnerships with eligible stakeholders including local and state provider agencies; and    promoting communication among critical stakeholders to capture and analyze program data.    
     
     
         56 ) An information technology (IT) platform for providing coordinated health care and human services management comprising: 
 a healthcare management service;    a self-management service;    a community and vocational service;    an outcomes research service; and    an IT platform combining access to said services for coordinating and managing said services within said information technology (IT) platform, wherein the information technology (IT) platform is a population-based, client-centric entity that facilitates a focusing of a client's functional and psychosocial needs on community integration and re-employment through the coordination and interaction of said services.    
     
     
         57 ) The information technology (IT) platform of  claim 1 , further comprising public and private services, wherein 
 the public services includes at least one of general program marketing information, general e-mail, calendar, discussion groups and forums and general job placement information, and    the private section of the platform is secure and private, and is divided into two main applications wherein the first application contains clinical and self management data, and the second application contains community and employment service information.