2020 Collection of Project Unify User Stories

The following is the 2020 collection of Project Unify User Story summaries. Each summary explores a particular challenge in cross-domain interoperability and integration. The entire series follows the Thomson family through the trials and tribulations of their difficult lives, and the community and societal help they need to survive. Each story has been or will be developed in more complete detail as needed for demonstrations. (For example, the 2019 MITA-TAC Adult Opioid Story was fully developed as a detailed, five-page 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 at the idea of rejoining his wife, Sarah, and son, Jameson. His many deployments have been physically and emotionally difficult. A PTSD diagnosis contributed to his decision to leave the military. John’s deployments have also been hard on his family. During his absences, Sarah became addicted to opioids and doctors grew 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 decided 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 healthcare coordination, Sarah could have been helped to successful complete substance-abuse rehabilitation; Jameson could have received appropriate healthcare and therapy; and John could have been supported with PTSD therapy 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, resulted in a divorce for John and Sarah. She and Jameson have moved 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. That resulted in her becoming the single mother of Jameson Thomson, age 7. Sarah and Jameson now 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 contribute financially or in any other way to help 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). In addition, she is six months pregnant and has several nonmedical issues relating to access to food, housing, and transportation.

One day Jameson’s First Grade teacher notices that the boy has come to school in a very drowsy condition, falling asleep several times at breakfast and in early-morning classes. The teacher sends Jameson to see Florence Whitaker, the school nurse. While Florence is talking to Jameson, she notices 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. Driving there under the influence of her medication, which makes her very drowsy, she falls asleep at the wheel and hits a lamp post; her car is totaled. 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 while she’s 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 with better prenatal care for the baby she’s carrying. 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, 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 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. Like her son, Jameson, Madison was born with Neonatal Abstinence Syndrome (NAS). Jameson, who is now 10, also has asthma. He has no medical home, gets minimal well-childcare, 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 years; moving away from his friends each time he was placed in foster care and 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 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 he has 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 opioids 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 healthcare 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.

Single-Parent Social Determinants of Health (SDoH Story - Index Person: Sarah Thomson)

Sarah Thomson, who is 30, has had a tough life since she divorced her husband, John Thomson. She has no personal savings and is barely making ends meet with a minimum-wage factory job. She has two children, 3-year-old Madison and 10-year-old Jameson. Jameson has returned from foster care, in which he was placed due to Substance Use Disorder challenges for both Sarah and Jameson. Each is doing better as a result of behavioral and physical health intervention. Sarah has continued to work with a social services case manager to gain benefits and services to support her and her two children. The social services case management system has some Social Determinants of Health (SDOH) screeners that are triggered and, consequently, a patient search is generated in their local/regional Health Information Exchange (HIE).

Finding a match for Sarah's health record in the County Health Department system, the case management system transmits her SDOH data to the HIE. The HIE adds this data to Sarah's patient health record, which may be combined with SDOH data from other sources, including medical survey results. With five high-risk SDOH elements for Sarah and her family, emergency intervention resources are recommended. With integration of SDOH information across both social services case management and healthcare coordination systems, there is the ability to identify supportive social benefits and services, determine eligibility, complete and submit referrals and applications, and closed-loop enrollment notifications to all systems.

Desired Outcome: With appropriate cross-domain social services, case management and healthcare coordination, Sarah and her family could be helped through continued substance-abuse rehabilitation; be provided with better resources to stabilize her family's lives and improve their well-being, based on an understanding of her SDOH needs such as secure housing, career training, a job apprenticeship, food stamps, and cash assistance.

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 her opioid rehabilitation, and reunite with his son. Things did not go as he hoped, however. 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 self-medicated with alcohol and, after many tempestuous months, the couple agreed to a divorce.

Without any 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, and he could be provided with better resources to stabilize his life and further his well-being, 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.

Homeless Infectious Disease Transitions (COVID Story - Index Person: John Thomson)

Technical Sergeant John Thomson has been enrolled in a shelter program supported by a Homeless Management Information System (HMIS). He has been living in various congregate shelters during an infectious disease pandemic. Unfortunately, such shelters make it difficult to "socially distance" and many do not allow daytime "shelter in place," resulting daily physical health challenges and high disease transmission rates. John has been feeling unwell for a couple of days and notices he is especially fatigued as he is turned out of the shelter for the day.

John visits a local critical care facility; his recent health history and vitals (a temperature of 100.3) indicate he has an "unspecified respiratory infection." As a result, he is tested for COVID-19 at a site adjacent to the care facility. While he waited to be tested, the facility’s Electronic Health Records (EHR) system issued a standard Admit Discharge Transfer (ADT) alert to the Regional Health Information Exchange, indicating John had been transferred to the testing facility. This ADT triggered an independent homeless person COVID screener to recognize that this specific homeless person may have COVID. The screening system issued a message to the originating EHR to direct John to a special quarantine shelter after discharge from the facility.

(This independent screener attempts to protect the homeless client’s privacy and housing status from the healthcare system, while also protecting the general public’s healthcare information from the homeless management information system, by providing a neutral trusted system to subscribe to ADT COVID alerts for a set of pre-matched patient IDs. As far as the healthcare system can tell, these pre-match patient IDs could represent foster children, homeless persons, recent travelers, or any number of other target groups of concern for COVID infection. The HMIS will only get the medical records of homeless people who are suspected or confirmed to have COVID and who have consented for the HMIS to access those records.)

Desired Outcome: With appropriate cross-domain homeless shelter management and healthcare coordination, John could be directed to a quarantine shelter (often in hotel rooms). This would reduce the potential for continued disease spread through the shelter populations.

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