In the U.S., social services like state-funded medical care, mental health services, housing support, and food assistant programs exist as independent organizations; yet, the effectiveness of each depends largely on how they work together within the broader provider network. While a single social service organization may be equipped to help someone who seeks support, the larger system of providers is structured in a way that makes it difficult for them to communicate about a person’s needs in a holistic way. Our client, Lutheran Social Services of Illinois (LSSI), faces this challenge daily as the largest social service organization in the State of Illinois. Fjord and Accenture teamed with LSSI to explore how technology could eliminate this fragmentation and strengthen care coordination across providers.
Through primary research with 25 employees across six different provider sites, we learned that delivery of LSSI services (mainly mental health services and alcohol/drug treatment) is reliant on a network of providers that isn’t currently integrated to its fullest potential. Case managers must coordinate treatment plans for clients to address individual needs with consistency, and fragmented communication across this network creates hurdles to helping those in need. Specifically, there wasn’t a universal platform to track a client’s treatment plan as they moved between social service agencies – so, for example, supporting a mentally ill client, who might also be homeless, became difficult when that client was referred to a housing agency, food assistance program or hospital outside of LSSI’s network.
Our team designed the Whole Person Care Journey, a tool that helps case managers efficiently coordinate care by giving them the power to digitally view clients’ attendance to appointments and engagement with other services, both within and outside the LSSI network, in real time. A client’s Care Journey is updated as they check in at different locations with their Care Ticket, an easy-to-generate visual code embedded with anonymized data (such as a QR code), in the form of printed card or sticker. Their case managers, who may only meet with clients once per week, are then able to confirm as clients arrive at their appointments. The Care Journey tool also incorporates an analytics feature that aims to provide a high-level view into success metrics that matter the most to stakeholders across the care network and its payers.
To test and refine our concept, we prototyped the digital timeline portion of the tool with LSSI case managers. They used the tool in their daily interactions with clients, and we worked closely with our users to gather feedback and refine the design. During this prototyping phase, the case managers found the tool helpful in beginning to identify patterns between client success and their level of engagement with different services. Furthermore, they also saw potential in the digital journey as a way of enhancing their communication with clients and keeping them accountable for meeting their goals.