ACCESS Sonoma County

About the Program

Category: Health (Best in Category)

Year: 2019

In April 2017, the Sonoma County Board of Supervisors established the long-term strategic priority of strengthening the County’s Safety Net system with the goal of identifying our most vulnerable residents and developing coordinated strategies to improve their well-being, self-sufficiency, and recovery. In response, the Sonoma County Safety Net Departments developed an initiative called Accessing Coordinated Care to Empower Self Sufficiency (ACCESS) Sonoma County. This program identifies our most vulnerable residents who are experiencing homelessness/housing insecurity, behavioral health, substance use, unemployment, and criminal justice issues, and strives to provide the help they need to improve their self-sufficiency and well-being. In support, the County partnered with IBM to develop an integrated care delivery system that combines information from mental health, substance use, social services, housing, and justice databases, with the IBM Watson Care Manager to provide critical information and care coordination tools to our care teams. Using these tools, our Interdepartmental Multidisciplinary Team (IMDT), consisting of health care, social services and criminal justice professionals, provides outreach, engagement, and care management to help address the issues impacting our clients. This combination of an Interdepartmental Multidisciplinary Team and powerful care management tool has produced results not possible with fragmented information from siloed systems.