American Rescue Plan Act Funding for Home Visiting - Innovation - Annotation: The State of Oklahoma proposes to introduce technology-driven innovations aiming to streamline and amplify the methods of care coordination among home visiting (HV) programs managed under the Oklahoma State Department of Health. The core innovation component relies on a readily available, end-to-end systems of care solution, the Unite Us social care application. The introduction of this bidirectional, electronic care coordination and data exchange system specifically targets narrowing inequity gaps in client access to care and supports. Problem: Phased application usage is strategically planned around connecting clients to critical social supports impacted by the pandemic and strongly related to social determinants of health. Targeted areas include connections to: (a) State’s Legal Aid Services Organization to combat housing, utility, and food crises; (b) State’s Early Intervention system, SoonerStart, to address concerns of developmental delays exacerbated by pandemic isolation; and (c) newly developed Parent Child Assistance Program to combat pandemic spikes in alcohol and substance abuse among young adults. Purpose: The proposed work plan touches upon all 4 priority areas outlined in this HV Innovation Award Funding Opportunity Announcement. Use of this technology solution will enable point-of-care data capture of social and structural determinants of health affecting eligible and participating home visiting clients (Priority 1). Unite Us will also expedite integration of these data (Priority 2) across systems of care that confront disparities in neighborhood adversity, economic stability, education, healthcare, and basic necessities. The bidirectional data exchange facilitated by this innovative portal will also amplify efforts to recruit and retain HV clients (Priority 3). A stronger referral network will promote greater home visiting access for those historically unserved but who seek care from the critical service agencies highlighted above. Relationships with these designated agencies are dual purposed and intentionally selected to also address client crises that frequently precede HV service dropout. Better client access to supports during times of crisis is theorized to enhance caseload retention. Finally, the use of these tools will also be accompanied by new worker trainings (Priority 4) on incorporating the applications in practice, best practices on identification of needs and risks, and the benefits of local crisis interventions. Goal(s) And Objectives: The major goals of the project are to expand and strengthen HV’s community support network and equip HV providers with next generation influx and efflux referral technology and training to reduce known health and social care disparities among home visiting families who are most vulnerable to crises associated with the pandemic. Goal attainment aims to accomplish the following objectives: (1) increase the number of referrals for HV services, (2) increase the number of outgoing referrals to quality services, (3) close the referral loop for outgoing referrals to LASO, SoonerStart, and PCAP, (4) increase retention of clients, particularly among groups facing care inequity, (5) enhance the assessment and care coordination skills of our HV workforce, and (6) disseminate lessons learned and implementation successes to the national HV community. Methodology: To accomplish goals, OSDH will contract with the Center on Child Abuse and Neglect (CCAN) at the University of Oklahoma Health Sciences Center (OUHSC) to coordinate community partnerships and phased implementation of the applications throughout designated regions of the state. This work will be aided by an ongoing learning collaborative of HV local implementing agencies currently led by CCAN faculty. Regional roll-out of the applications will be staggered to facilitate effective implementation but also to add rigor to an evaluation of innovation impact on service delivery. The stepped
