Priority Initiative 3: Enhanced Care Coordination

“To connect vulnerable older adults to resources with a whole person care approach.”

Priority Initiative 3 Enhanced Care Coordination

Priority Scope

Through this initiave, the County will leverage partnerships, both existing and new, to better connect older adults to resources with a whole person care approach which may include:

Resource Opportunities (e.g., housing, transportation, food assistance)
Health Care Resources
Public/Personal Safety Information (e.g., elder abuse and fraud prevention)
Job Placement Opportunities
Inclusion Opportunities (e.g., volunteer opportunities, older adult activities)
Legal Planning Resources

The long-term vision for enhanced care coordination uses data to ensure the effective and efficient connection of resources and opportunities to individuals. As a result of coordinating services such as scheduling multiple service appointments back-to-back, barriers related to transportation can be minimized or eliminated.

Background & Supporting Data

Identified Need to Provide Coordinated Services to Reduce Barriers for Older Adults

Although OC has a high ratio of available health care professionals for the population, accessing care and resources is not always easy for older adults. The OC Paid Provider Survey results revealed that slightly over half of paid providers felt services were moderately accessible because of the required effort and flexibility of older adults. Additionally, the OC Older Adult Community Survey results indicated that the following barriers prevented older adults from seeking medical services:

Appointments not being available at convenient times (38%)
High cost for copays (30%)

Don’t know where to get help (26%)
Lack of transportation (19%)
Locations being too far away (14%)

These barriers were also relevant to those who needed behavioral health services. In terms of transportation, community ratings among cities in ease of transportation ranged from 23% to 78%, with an average of 41%. Disparities among community ratings as well as demographics highlight the importance of tailoring efforts to connect individuals to appropriate services, support, and programs.

Resources & Potential Considerations

OC Cares

OC Cares is a countywide initiative addressing the needs of OC residents and accessibility to services and programs through the County’s five Systems of Care: behavioral health, healthcare, housing, or benefits and support services and community corrections, and includes coordinated care management, linkages to programs and services, and assistance with job readiness and employment.

Strategic Priorities

Care Coordination has been identified as an Emerging Initiative and Strategic Priority in the 2016 to 2023 SFPs. The Priority initially addressed care coordination surrounding individuals experiencing or at risk of becoming homeless but was expanded to allow for better coordination of services and robust data and metrics reporting for additional populations. Replicating this structure, the County will use Compass OC, the County’s internal data sharing platform, to enhance care coordination for older adults.

The Care Plus Program (CPP)

CPP offers enhanced care coordination for those who are the most vulnerable across the County’s System of Care: Behavioral Health, Community Corrections, Healthcare, Housing, and Benefits and Supportive Services. The program objectives are to expedite the identification of client needs and provide subsequent linkages to services with greater collaboration and maximization of resources. The program is facilitated through the innovative data integration platform Compass OC and the use of multidisciplinary team meetings.

Compass OC

Enables data sharing between County departments and community-based organizations by pulling specific data elements from numerous County databases to create a holistic view of a client’s program history and service utilization. Additionally, Compass OC facilitates the creation of Care Plans for clients, including referrals and linkages to services, to assist in care coordination and case management. Multidisciplinary teams, comprised of subject matter experts across the System of Care, meet on a regular basis to support and inform the development of Care Plans and coordinate approaches to overcome barriers to care for clients of the CPP.

Advisory Committees

The OC Older Adult Advisory Commission (OAAC), OC MPA Steering and Advisory Committee, Care Plus Program Steering Committee.

Healthcare Coordination

Health care coordination ensures that health care providers coordinate the physical, dental, behavioral and social services of their patients. Agencies must follow State and Federal regulations to ensure that their respective health plan members receive timely access to appropriate care, and within OC the Health Care Agency and managed care plans are working to ensure individuals with high-needs and receiving MediCal have coordinated access to clinical and social services.

Community Partners and Key Stakeholders

Development of this initiative may lead to the identification of vital outside County stakeholders, contracted providers, community-based organizations including existing contracted care coordinators, local partner agencies (i.e., OC Transportation Authority, Cal Optima, etc.) and other community stakeholders.

Objective Overview Enhanced Care Coordination

Objective 1 \| Long-Term
Implement a data integration program to enhance care coordination for OC older adults and their caregivers through the design of an aging cohort to address their needs across the Systems of Care.

Item Number & Description	Key Stakeholders - Implementors
FY 2025-2026 Action Items
1.1 Utilize OC Older Adults Needs Assessment and additional external assessments available to identify the specific needs of older adults and their caregivers related to care coordination and the needs/gaps in data sharing.	County / Community
1.2 Develop an implementation plan, including relevant key performance indicators (KPI)s and outcomes, for initial phase of integration including identification of source systems, relevant data points, case study, methodology, etc. in collaboration with the County’s CEO Office of Care Coordination, Data Analytics and Information Technology teams.	County / Community
1.3 Develop Data Sharing Agreements: Establish agreements with relevant County stakeholders to ensure secure and compliant data exchange.	County
1.4 Determine the scope and responsibilities for an Aging Cohort and CPP parnership that best serves older adults needs and establish a ‘no wrong door’ approach for older adults to access the care coordination team.	County
FY 2026-2027 Action Items
1.5 Expand upon the use of Compass OC to include an Aging Cohort that will enable users to share relevant data, securely and with authorizations to disclose as required, from across County departments for greater care coordination and successful linkages to resources otherwise difficult to access.	County
FY 2027-2028 & Ongoing Action Items
1.6 Utilize the Aging cohort to guide future coordination efforts and collaboration by providing complementary information to reduce duplication of effort.	County / Community
1.7 Create predictive analytic models to determine data driven recommendations to guide service models and care coordination based on the needs of the Aging Cohort.	County
FY 2030-31 Action Items
1.8 Report recommendations for next steps and sustainability of this initiative.	County