The goal is to make integrated service delivery the way we do business everywhere, fully integrated throughout our system and the way we exist.
Michelle DeArmond, Executive Director, Riverside University Health System
Background
Riverside County is home to 2.4 million residents. It is the fourth largest county in California and has more residents than 16 US states. Unfortunately, it is also one of the poorest and most unhealthy counties in the State.
Business Goals and Challenges
Among the challenges Riverside County faces are the large population, vast geographic area, diverse needs, and barriers to understanding and accessing services. Riverside County identified these specific goals and challenges:
- Outreach and Prevention: The County recognized that a proactive approach using a model focused on outreach and prevention was needed to link eligible residents to needed services.
- Service Identification and Care Coordination: The County’s health and human services system lacked mechanisms to tackle social determinant factors, which can drive up to 80% of health outcomes, effectively. County staff envisioned an ecosystem of partners providing services to County residents.
- Whole Person Health Score (WPHS) and Healthy Places Index (HPI) Score: In 2016, the Riverside University Health System (RUHS) created a Whole Person Health Score (WPHS) assessment, a survey with questions from socioeconomics to physical and emotional well-being. In addition, the Healthy Places Index (HPI) measures overall healthiness of the community based on social determinants of health including housing, education, transportation, and environmental conditions. Riverside County’s goal is to improve residents’ WPHSs and to increase its HPI score by 30 points in 30 years.
RivCoONE - An Integrated Service Delivery (ISD) Solution: To address the problem of fragmented services across the breadth and complexity of resident needs, Riverside County’s health and social services departments adopted a person-centered, coordinated system of care and integrated service delivery (ISD) model called RivCoONE. The objective was to implement RivCoOne across departments throughout the County, targeting 30 sites in three years (2023-2025).
Solution
Riverside County brought together key business stakeholders across their health and human services ecosystem in a Design Thinking workshop to create the RivCoONE ISD model. The County invited IBM to the workshop to outline current business processes, ideate regarding future business processes, and document findings that informed a path toward the RivCoONE model. Workshop participants examined challenges and generated ideas to positively impact WPHSs for Riverside County residents and ultimately increase the County’s HPI score.
Simpler Consulting, an IBM company, has been a valued partner in formulating the Transformational Strategy to improve the health of residents in Riverside County. Simpler Consulting’s collaborative work and strategic partnership with the County and the County’s primary healthcare provider, RUHS, has made Simpler the trusted advisor and facilitator of transformational change for Riverside County.
Examples of the impact that RivCoONE, guided by Simpler, delivered for the County are:
- Simpler, utilizing its Simpler Business System approach, partnered with executive leadership to establish a roadmap for the RivCoONE initiative. The team developed a map of the ideal, streamlined process that minimizes waste, maximizes process flow, and delivers the most value to patients.
- Simpler integrated the WPHS assessment by having resource specialists at RUHS assist patients in completing the assessment. These efforts have resulted in 80% of patients completing the assessment since the launch of the RivCoONE initiative in May 2023, up from 38% before the resource specialists came on board.
- Simpler's Future State Implementation continues the partnership with RivCoONE teams.
Outcomes
Riverside County shifted from a program-focused mission to a person-centered, Whole Person Care approach and an ecosystem of care that addresses not only medical needs but also social determinants of health. Nearly half of Riverside County departments now operate using ISD on a day-to-day basis.
The improvements in effectiveness and efficiency driven by the RivCoONE model and the Simpler Consulting engagement are shown by positive trends in patient health, with 80% of patients completing the assessment and a 95+% show rate for follow-up appointments, demonstrating high patient engagement with the service model.
Moving Forward
Riverside County’s long-term partnership with Simpler Consulting/IBM has refined the County’s business model to be more efficient and cohesive in delivering high-quality, person-centered care, addressing both medical care and needs related to social determinants of health. This has led to improvements in health outcomes and patient satisfaction and to a reduction in the overall cost of healthcare for the residents of Riverside County.
