The following is the 2020 collection of Project Unify User Story summaaries. Each summary in the series explores a particular challenge in cross-domain interoperability and integration. The entire series follows the Thomson family through the trials and tribulations of a difficult set of lives which require community and societal help to survive. Each story has been or will be developed in more complete detail as needed for demonstrations. (E.g. the 2019 MITATAC Adult Opioid Story was fully developed as a 5 page detailed user story.)
DOD-to-VA Transition Assistance (VA/VHA 2020 Story - Index Person: John Thomson)
Technical Sergeant John Thomson has separated from the US Air Force due to personal health and family hardship after a career with long overseas deployments. He is delighted to be able to rejoin his wife, Sarah, and son, Jameson. His many deployments have been physically and emotionally hard on John. He was diagnosed with PTSD, which contributed to his decision to leave the military.
His deployments have also been hard on his family. During his long absences, Sarah became addicted to opioids and doctors became concerned about Jameson’s frequent trips to the emergency room for asthma attacks and physical injuries, including some that appeared to be self-inflicted.
Primarily because of those family crises, John decides to leave the military without completing the normal one- to two-year Transition Assistance Plan (TAP). His transition counselor now has the challenge of supporting John, Sarah, and Jameson as they transition without receiving the routine preparation that families normally get. Such preparation would have been particularly helpful in this case since it is so complex.
Desired Outcome: With appropriate cross-domain social services, case management, and health care coordination, Sarah could have been helped through successful completion of substance-abuse rehabilitation; Jameson could have received appropriate healthcare and therapy; and John could have been supported with therapy for his PTSD and re-integrated into the family structure.
Setup for the next scenario: Unfortunately, the many stresses on the family, combined with each individual’s personal challenges, result in a divorce for John and Sarah. She and Jameson have move into a tiny apartment in a poor area of Temperance, MI.
Adult Opioid (MITATAC 2019 Story - Index Person: Sarah Thomson)
When Sarah Thomson was 27 years old she divorced Air Force Sergeant John Thomson. At the time she was the newly single mother of Jameson Thomson, age 7. Sarah and Jameson live just above the poverty line in a tiny apartment in a run-down, non-rent-controlled building in Temperance, MI. Her ex-husband is living in a homeless shelter in another state and is not able to provide for his ex-wife or son.
After being injured at her warehouse job a year ago, Sarah got hooked on opioids, which caused her to develop acute kidney disease; she also had asthma. She is currently receiving court-ordered Medication Assisted Therapy (MAT). 6 months’ pregnant she has several nonmedical issues relating to access to food, housing, and transportation.
One day Jameson’s First Grade teacher, notices that Jameson has come to school in a very drowsy condition, falling asleep several times at breakfast and in early morning classes, and sends Jameson to see Florence Whitaker, the School Nurse. While Florence is talking to Jameson she happens to notice what looks like an empty prescription bottle in his book bag – when she examines it, she finds it is from his mother’s buprenorphine prescription.
Sarah is called to the school to respond to this crisis. Sarah is under the influence and very drowsy, falling asleep at the wheel and totaling her car. She is rushed to the hospital by ambulance. She’s familiar with the emergency room; it’s where she and Jameson get most of their healthcare when they need it. Sarah receives treatment for minor injuries in the ambulance, then again in the hospital. The next day, she’s charged in court with driving while under the influence and reckless endangerment. As a result of the charges that landed her in court – as well as concerns raised by Child Protective Services and her ex-husband’s absence, Jameson is placed in foster care and, as a result, must change schools (among many other aspects of life).
Desired Outcome: With appropriate cross-domain social services, case management and healthcare coordination, Sarah could have been helped through successful completion of substance-abuse rehabilitation and been provided better prenatal care for the baby she’s carrying; and Jameson could have been provided with appropriate healthcare and therapy, spent less time in foster case, and re-integrated into his family.
Behavioral Health for Children and Youth (InCK NIC/MITATAC 2020 Story - Index Person: Jameson Thomson)
Sarah Thomson, now age 30, is a medically complex patient with multiple chronic conditions (asthma and heroin-induced nephropathy, which has not yet progressed to End-Stage Renal Disease). She is still under court-ordered Medication Assisted Therapy (MAT) for Opioid Use Disorder. She has been divorced from Air Force Technical Sergeant John Thomson for three years and has been raising her two children as a single parent. They live in a run-down area of Temperance, MI, near a furniture manufacturer and a large farm, with associated air and water quality issues.
Since we last checked in on our scenario family, Sarah gave birth to a daughter, Madison, who is now 3 years old. Like her son, Jameson, Madison was born with Neonatal Abstinence Syndrome (NAS). Jameson, who is now 10 years old, also has asthma. He has no medical home, gets minimal well-child care, and receives most of his healthcare at the ER or urgent care facilities He has watched far too frequently as Emergency Medical Services personnel came to his house to resuscitate his mother. He has been in and out of foster care and has been receiving behavioral health therapy ever since Child Protective Services intervened as a result of his Adverse Childhood Experiences (ACEs), which were directly and indirectly due to his mother’s addiction.
Jameson was held back to repeat first grade but has never been screened for nor diagnosed with any developmental disabilities. Jameson has been traumatized in many ways – being separated on-and-off from his mother and from his father for year; moving away from his friends each time he was placed in foster care; living in care with a different, unfamiliar family each time; and being placed repeatedly into new schools in which he knew no one. During the same period, he has been detached from his personal support system, even as he has been challenged by the new experiences of meetings with an overloaded case manager, appearances in family court, and the stress of his mother’s addiction and his father’s ongoing absence.
Jameson becomes withdrawn at school and testy with his foster parents. When he moved into his most-recent foster placement, he left his medications behind and has neglected to continue his asthma-controller inhaler treatments; it’s no surprise that his physical and mental health have declined. In addition, although he is getting behavioral health therapy, Jameson uses drugs and alcohol to cope with his misery and anxiety.
One day Jameson’s fourth-grade teacher notices that he has once again come to school appearing to be under the influence. She sends Jameson to see Florence Whitaker, the school nurse, and writes up an incident report in the School Management Information System (SMIS) on her laptop.
Florence begins taking Jameson’s vital signs and recording them in the School’s Electronic Medical Records (EMR) system. She suspects misuse of opiods to be the cause for Jameson’s drowsiness, so she opens a triage instrument to ask some questions and record her observations. The Triage tool guidance suggests an intervention: Notify the School Assistance Team, which is made up of Florence, the principal, and Gerald Brown LSW, a social worker in the Michigan Department of Health and Human Services (MDHHS) Monroe County office.
After discussing the case, the team determines there is enough evidence to trigger a SMIS-generated Mandatory Report to Child Protective Services. Jameson’s child welfare case manager receives the Mandatory Report and now needs to work with the boy’s assigned primary care physician, a psychologist, teachers, foster parents, and the family court to revise Jameson’s Service Plan to ensure he gets additional behavioral health support and substance-abuse rehabilitation. In addition, the case manager initiates a Health Care Plan with Jameson’s Primary Care Coordinator via a FHIR Care Plan Resource.
The Primary Care Coordinator evaluates the requested Care Plan, updates it to reflect medical necessity, and generates a FHIR eLTSS Resource (electronic Long-Term Support Services request with Care Plan and associated Referrals), which is sent to each of the behavioral and physical health specialists needed to help Jameson get well.
Desired Outcome: With appropriate cross-domain social services, case management, and health care coordination, Sarah may finally be helped through successful completion of substance-abuse rehabilitation; her daughter, Madison, could be provided with better early-life care; Jameson could receive appropriate healthcare and therapy; and, once Sarah is clean and sober, her son could be re-integrated into the family.
Homeless Social Determinants of Health (SDoH Story - Index Person: John Thomson)
Technical Sergeant John Thomson has had a tough life since he separated from the Air Force. He returned from his final deployment anxious to save his marriage, support his wife through opioid rehabilitation, and reunite with his son. Things did not go as he hoped. Because he left the service without the required transition assistance planning, he has had difficulty finding a steady job, lacks savings to buffer his transition and, with untreated PTSD, has had an angry and violent relationship with his wife, Sarah. He turns to alcohol. After many tempestuous months, Sarah and John agree to a divorce.
Without any personal savings or a job, John is now homeless in Michigan. He enrolls in a shelter program supported by a Homeless Management Information System (HMIS). The HMIS monitoring his enrollment has some Social Determinants of Health (SDOH) screeners that are triggered and, consequently, a patient search is generated in the homeless client's local/regional Health Information Exchange (HIE).
Finding a match for that homeless person's health record in the County Health Department System, the HMIS transmits his SDOH data to the HIE. The HIE adds this HMIS-transmitted data to the homeless patient's health record, which may be combined with SDOH data from other sources. With five high-risk SDOH elements for this individual, emergency intervention resources are recommended for him.
Desired Outcome: With appropriate cross-domain social services, case management and healthcare coordination, John could be helped through substance-abuse rehabilitation; he could be provided with better resources to stabilize his life and further his wellness, based on an understanding of his SDOH needs such as secure housing, career training, a job apprenticeship, food stamps, and cash assistance. With John “back on his feet,” he also might reconnect with his family, whom he misses dearly.
Infectious Disease Shelter-in-Place (COVID Story - Index Persons: Fred and Sharon Mertz)
While their physical health is currently good, Sarah Thomson, her 10-year-old son Jameson, her 3-year-old daughter Madison, and her parents, Fred and Sharon Mertz, are sheltering in place in Sarah’s tiny apartment. With the rapid expansion of a pandemic, regional government agencies have required community lockdowns to enable containment; the Thomson family has chosen to self-quarantine to avoid infection.
In addition to raising Jameson and Madison as a single mother, Sarah is also caring for her parents. She removed them from their nearby low-income assisted-living facility because they are elderly and have potential co-morbid chronic illnesses. Fred and Sharon are amongst the most vulnerable of populations who rely on social services for their meals, for help with daily hygiene and, most important, for monitoring of their health, especially during a pandemic. Since Sarah moved her parents, the assisted-living facility has reported many infections and even a few deaths. Sarah and Jameson both have asthma, so they are also at high risk and are very worried about caring for Fred and Sharon. Sarah is especially stressed and overwhelmed by her family responsibilities and needs support from social services.
Desired Outcome: Social services case management could enable Fred and Sharon, as well as Sarah, to receive better nutrition through SNAP and TANF. Meanwhile, home care aides could help Sarah care for her elderly parents; monitor Fred’s and Sharon’s health; and assist with grocery and pharmacy shopping while all are under stay-at-home orders. In addition, from an epidemiological perspective, early identification of infection drives both treatment of illness and identification of close contact with potential future patients that must now be monitored. Social services case workers and managers become key partners to the healthcare community by providing daily support to locked-down or self-isolated communities and by helping in the early identification of new infection cases. Since Sarah’s apartment is too small for individual isolation, social services could also move anyone who became infected to a designated hotel.