The vendor is required to provide from organizations interested in providing a solution for our case management and electronic health records needs.
- Community and public health (CPH) vision:
• HOP – homeless outreach program: provides targeted outreach and intensive case management to homeless individuals throughout state springs.
• TAP – transition assistance program: provides intensive community navigation services for inmates of the EL paso county criminal justice center (CJC) identified as high risk and high need, as well as providing navigation at the state springs municipal court and the EL paso county jail.
• App – aging in place program: developed to help identify and support aging community members who may need additional support to remain in their homes or identify those who may need navigation assistance to a safe living arrangement and improved quality of life.
• Super-utilizers program: developed to help identify individuals who have six emergency response calls within six months with the intent that if we provide supportive services, they will have less need for emergency response services.
• CRT – community response team: developed to assist patients suffering from acute behavioral health crisis by employing cross-agency collaboration to integrate behavioral health services into the broader healthcare spectrum.
• ART – alternate response team: expands the scope of collaborative response in our community by responding to low acuity 9-1-1 calls while the CRT units are responding to higher levels of mental health crisis.
• TOR-MAT – targeted opioid response: medication assisted treatment – a program designed to support individuals who have had an overdose on opioids to offer resources and initiate medication assisted treatment.
- Case management:
• A client may have multiple cases over time, with one or more of the various CPH subprograms. a client can only be enrolled in one CPH sub-program at any given time.
• The CRT and art programs are incident based and a client enrolled in a CPH sub-program may have an incident with either the CRT or art teams while their case is still active in one of the other sub programs.
• Ability to track sub-program enrollments by start and finish dates
• Ability to clearly see which program the client is actively enrolled in, but also be aware of previous enrollments and have the ability to drill down into those past case histories.
• Ability to provide a quick snapshot of a client’s chart which would include:
o Record status
o A calendar view showing most recent and upcoming scheduled appointments, along with the disposition of the most recent appointments
o Basic demographic information
o Presenting problem or health issue
o Diagnosis and medical history
o Historical appointments and their disposition
o Applicable case alerts
o Date of last service we provided, and the type of service that was provided
o Summary view of care plan, progress, and next steps
o Ability to see or manage any critical custom flags or fields – for instance, a flag that identifies the individual needs to be located.
o Ability to manage and see who we have referred a client to, and where the client was referred to us from.
- Profile information
• Ability to capture standard demographic information such as first and last name, nickname, date of birth, sex, gender (LGBTQ+), veteran status, contact information, emergency contact information, ethnicity, etc.
1. Ability to flag information as no longer active but still retain it, view it, and search on it.
2. Ability to attach related documents, such as a copy of a power of attorney.
• Ability to capture basic health information, such as vitals, respirations, if they were discovered with a medical issue what their condition was, EKG, allergies, medications, etc.
1. This information is often collected by mobile response teams out in the field.
2. This type of information may be collected over multiple instances across time for the same client.
• Ability to capture medical history information (from multiple sources), including:
1. Dates of past visits, issue seen for, treatment provided, provider name, etc.
2. Medication history
3. Drug and urine screenings, pregnancy or other lab test, x-ray or other diagnostic tool results.
4. This type of information may be collected over multiple instances across time for the same client.
• Ability to capture information associated to allergies or potential negative responses to specific medications.
• Ability to capture medication information, including name of medication, timespan taking it, dosage, frequency of dose, and prescriber.
• Ability to capture disability information
• Ability to configure assessment or care templates within the system, and then to administrate those assessments and have that information captured as part of the client’s case record; assessments may include:
1. Safety plans
2. Access to a counselor
3. Columbia suicide assessment
4. Stanley brown
• Ability to flag a client account as “high risk” or “needs follow-up”, and a way for the navigator to quickly see all accounts in their case load with these flags, or for a manager to see all accounts with these flags across multiple navigator caseloads.
1. Ability to set reminder notifications for some of these flags – for example, if the client is flagged as “needs follow-up”, notify the navigator every 3 days until the follow-up event has occurred.
• Ability to flag a client’s record as “not available for sharing” in total – this flag would prevent system users from being able to generate either a digital or physical (printed) “package” of information about this specific’s client case unless approved by a supervisor with appropriate permissions.
1. Ability to de-duplicate records, including:
2. Display of potential matches when searching records across a broad spectrum of the client’s profile information – this may include things such as “nickname”, or a combination of factors, such as the same phone number or email address, or multiple interactions within the same general location
3. Ability to run a scheduled “de-duplication” process that presents potential duplicate records to a human being to resolve – they can determine they are not duplicates and leave them as individual records, or they can determine they are duplicates and merge the two records into one record.
4. The ability for a navigator to merge one client record into another client record manually if they are identified as duplicates.
5. The ability to “unmerge” two client records that may have accidently been merged in error.
- Interaction information
• Ability to track interactions in several ways:
1. As part of a specific client case record
2. As a one-off interaction for someone who is not currently on anyone’s caseload
3. As a group interaction where we distributed multiple resources to a group of people over a period of time during which we did not specifically identify any members of the group, but we do tally the number of people we engaged with as well as the number of resources handed out ideally this solution would allow us to capture this information in the field in a very simple manner using a hand-held device like a phone or tablet
• An interaction record that is part of a client case record should automatically capture the name of the navigator involved in the interaction from the person who is logged in that is inputting the information.
1. Allow this information to be overridden by users with the appropriate system permissions
• An interaction record that is part of a client case record should automatically capture the date and time of the interaction from the current date and timestamp on the device but must allow those values to be backdated if appropriate.
• Ability for navigators to log interactions with the client, including date and time of interaction, location, summary notes, and to assign one or more tags to the interaction tags should be able to be used for reporting, as well as potentially for alerting or automated notifications
1. Tag values must be custom definable within each individual CPH program
• Ability to denote the type of interaction from a custom pre-defined list.
• Some interaction types may be ones where we were attempting to contact the client but were unsuccessful in doing so, others may be “in person”, “phone call”, “email”, etc.
• Ability to track the types of services provided as part of that interaction.
• Ability to track the types and quantities of resources distributed as part of an interaction.
• An interaction record can also come from an external system, preferably via automated integrated means, for instance:
1. A one-time encounter with another CPH response program such as CRT or art
2. A 911 call response from our standard emergency services
3. An er visit with a local medical facility
• Ability to track an interaction with the client even after the case has been officially closed.
• Navigators should not be able to edit past records that represent specific interactions, however supervisors or those with appropriate system permissions should be able to edit this information if necessary.
- Care plan information:
• Ability to create an individualized care plan for each client
1. A care plan would include an overall objective, undergirded by one or more goals with target dates to achieve or complete each goal as the individual is moving towards the overall objective; in addition, it would capture regular review dates during which the plan is reviewed, as well as disposition information for each goal
2. Care plans should also have expiration dates, and a way to add one or more “tags” to any goal in the care plan to help us track information for grant or other reporting related to the impact our programs are having on our community.
• Ability to create “template” goals and steps in a pre-defined manner that navigators could select from to build their care plans, as well as allowing them to custom enter their own goal and associated steps, or to modify a template goal or step as needed.
- Ability to define which information in the case record is required by all of the following criteria:
1. Uniquely within each individual CPH program
2. By record status or another indicator of where a client is at in the process – for example, we may have a new client for hop where we do not yet have information on their age, their real name, or a direct way to contact them – need to be able to allow gaps in information during some stages of the relationship development that aren’t acceptable in a future stage and status.
3. To extend the example, we have a long-term client of hop for whom it would be required to have a birthdate, a valid name, and at least one form of contact information – in this later stage of the relationship, these fields are now required data.
4. The system must provide a mechanism to prompt for information that is now required prior to allowing a client to be moved into the next stage and status.
- Questions/Inquires Deadline: March 18, 2025