A COORDINATED COMMUNITY -...

A COORDINATED COMMUNITY:

PAServes – Greater Pittsburgh at Two Years

December 6, 2017

INTRODUCTIONS

OPENING REMARKS

Col. James D. McDonough Jr (Ret.)Managing Director, Institute for Veterans and Military Families

Misty HawkAssistant Vice President of Community Based Care, VA Pittsburgh Healthcare System

Raymond L. WolfeChief Operating Officer, Pittsburgh Mercy

Megan AndrosProgram Officer, Community and Economic Development, The Heinz Endowments

Jean CoyneSenior Manager of Intervention Services, Pittsburgh Mercy

PAServes-Greater Pittsburgh Coordination Center

OUR JOURNEY

WHAT ARE OUR GOALS FOR 2018?

WHERE ARE PASERVES &

AMERICASERVES GOING NEXT?

3. LOOKING

FORWARD

1. OUR ORIGINS

Today, we will be highlighting our origins and our impact,

showcasing the impact that the PAServes-Greater Pittsburgh

network has had on the community.

WHAT DOES THE

DATA SHOW?

OUR NEW

PLATFORM

2. OUR IMPACT

FROM BUILDING

BLOCKS TO IMPACT

FROM BUILDING

BLOCKS TO IMPACT

1. OUR ORIGINS

WILLIAM SORRELSPITTSBURGH MERCYPASERVES-GREATER PITTSBURGH

BEFORE UTILIZING THE

PLATFORM, THERE WAS A MISSING

PIECE: CENTRALIZATION.

WE STARTED OFF WITH A QUESTION:

HOW COULD WE TRANSFORM THE WAY VETERANS NAVIGATE THE

MAZE OF SERVICES IN GREATER PITTSBURGH, AND UNLOCK A

MORE EFFICIENT APPROACH FOR PROVIDERS TO DELIVER CARE?

PAServes Plans How to Serve

January 2015: Initiated a series of

IVMF facilitated strategy sessions,

during which the community defined

the requirements of their local

AmericaServes Network.

The Community Unites

October 2014: The Heinz

Endowments and Hillman Family

Foundation hosted a large convening,

bringing together providers and

supporters from the local Pittsburgh

community to discuss the region.

Pittsburgh Mercy

June 2015: The

Coordination Center RFP

was released in April, and

through a competitive

process, Pittsburgh Mercy

was selected.

Large and Diverse Network!

October 2015: Using the IVMF

& AmericaServes coordinated

care model, Pittsburgh area

providers began utilizing the

Unite US platform and better

serving military veterans and

their families.

WHAT BUILT PASERVES? THE COMMUNITY

Heinz Endowments

September 2014: Stemming from

its commitment to serve

Pittsburgh’s veteran community,

the Heinz Endowments provided a

planning grant for a local

AmericaServes Network.

AND SINCE LAUNCH, THE GROWTH OF THE

NETWORK IS UNPARALLELED.

Enlisting support

from public +

private

stakeholders

Evolved into leading example of coordinated

care, with more than 50 providers & support

from more than 6 universities and with

organizations like Team RWB, Mission

Continues and Leadership Pittsburgh Inc.

In October 2015, with

leadership by IVMF the

community launched a

network to coordinate

services

Expanding impact through

relationships with the Department

of Veterans Affairs and diverse

providers like Operation Troop

Appreciation. The VHA for

example came onboard to the

network and now facilitates 50+

referrals/month.

Enhancing technology

(Version 3 of Unite US)

to innovative new

versions!

BUILD SUSTAIN PARTNER LEADER TRANSFORM

IN THE TWO

YEARS: FOCUS

HAS BEEN

DEEPENING

IMPACT

WHAT DOES THE

DATA SHOW

2. OUR IMPACT

RIGHT PERSON RIGHT PROVIDER RIGHT SERVICE

Right Person

Our initial focus has been

from the start to connect

a veteran, family member,

or transitioning service

member to a service that

aligns with their needs.

We have more than 50

providers in our network

focused on serving their

clients through the

referral platform and

knowledge exchange

network.

Our outcomes are

continuing to show

greater impact to clients –

more timely and

appropriate referrals are

being made across the

board.

CLIENTS ARE KEY

THE CC REFERS TIM TO CASY,

WHO CAN HELP TIM REMOTELY. TIM MOVES TO

ALLEGHENY COUNTY. THE

CC REFERS HIM TO ADDITIONAL EMPLOYMENT PROVIDERS.

THE CC RECEIVES THE REQUEST, COMPLETES

INTAKE.TEAM RWBREFERS TIM INTO

THE NETWORK

He expresses a need for

employment assistance.

TIM, A NAVY VETERAN IN HIS THIRTIES, ENTERS

THE NETWORK WHILE STILL LIVING IN FLORIDA.

HE IS PLANNING TO MOVE TO ALLEGHENY

COUNTY UPON COMPLETING HIS EDUCATION.

July 2017

VLP OFFERS TIM A POSITION IN THEIR

ORGANIZATION

CASE IS CLOSED AND RESOLVED/SUCCESSFUL

THE CC REFERS TIM TO A BRAND NEW PROVIDER:

A RECRUITER AT UNIVERSITY

OF PITTSBURGH

October 2017

DUE TO PASERVES-GREATER PITTSBURGH,

TIM FOUND EMPLOYMENT.

TIM WORKS WITH VA VOC REHAB

AND VLP. THE CC ADDS HIM TO THEIR

EMPLOYMENT EMAIL LIST.

Requests

147

396

484

564625

584

710

599

0

100

200

300

400

500

600

700

800

0 1 2 3 4 5 6 7 8

Nu

mb

er

of

Cli

en

ts S

erv

ed

P

er

Qu

art

er

Quarter

PAServes-Greater Pittsburgh

fielded 4,109 requests in its

first two years of operation.

More and more community

members are served every

quarter.

On average, the network

growth trend is strong.

TIM’S REQUEST

IS NOT ALONE,

THOUGH.

WE’VE SERVED A DIVERSE SET OF CLIENTS

PAServes-Greater Pittsburgh has served as a one-stop-shop for more than

2,224 military-connected people since inception.

Clients Served

20%

FEMALE

9%

SPOUSES & FAMILY

34%

AGES 45 TO 64

21%

POST-9/11 ERA

2,224Clients

Clients Served

95

238

278

312337

320

360

284

0

50

100

150

200

250

300

350

400

0 1 2 3 4 5 6 7 8

Un

iqu

e N

ew

Clien

ts P

er

Qu

art

er

Quarter

…AND CONTINUE TO

SERVE THEM, DAILY

As is the case with service

requests, the growth trend

for new clients is strong.

+3.7% Increase in the number of

female veterans served from

year one to year two.

+4.5% From year one to year two,

more spouses and families are

being served.

69%6%

6%

19% Allegheny

Butler

Westmoreland

Undisclosed/Other

CLIENTS

BY

COUNTY

Web Form Requests

Coordination Center

Network Organization

AND REQUESTS

FULFILL DIFFERENT

NEEDS

Most Requested Services

On average, demand across service categories has remained

fairly constant, despite quarter-to-quarter fluctuations.

42%

PASERVES-GREATER PITTSBURGH FULFILLS

REQUESTS IN 15 SERVICE CATEGORIES, HELPING

CLIENTS ACCESS SERVICES IN ANY NEED.

15%

14%

10%

Individual &

Family Support

Housing & Shelter

Money Management

Employment

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5 6 7 8

% o

f S

erv

ice

Req

uests

Quarter

Housing Money Management Employment

Needs

Service Requests: Sources

39%

41%

Service Requests: Trends Outside of Individual & Family Support

20%

FOCUS GROUPS INFORMED BY DATA

ALLOW CARE COORDINATORS, PROVIDERS, AND PARTNERS TO

DISCUSS AND TAKE ACTION ON SPECIFIC TOPICS AND CHALLENGES


Right Provider










clients through the


knowledge exchange

network.

Our outcomes are

continuing to show


more timely and



board.

THE NEXT STEP: PROVIDER NETWORK

Purpose

TO FULFILL ALL OF THESE REQUESTS,

WE HAVE CREATED A TRUSTED

PROVIDER NETWORK

OUR PROVIDERS ARE COMMITTED TO

IMPROVING HOW CARE IS DELIVERED

VA PITTSBURGH

HEALTHCARE

SYSTEM

Misty Hawk, LCSW

Assistant Vice President of

Community Based Care

A DEDICATED PIONEER

The VA's early commitment

to PAServes as the way to

improve care for veterans

and military families was

integral to building and

sustaining community

support – and set a critical

example for future

AmericaServes communities.

COMMITTED TO

SERVING CLIENTS

BETTER…

837Referrals

Created

51

159

0

20

40

60

80

100

120

140

160

180

0 1 2 3 4 5 6 7 8

# C

los

ed

Re

qu

es

ts

Quarter

VETERANS

LEADERSHIP

PROGRAM

Ben Stahl, D.Sc.

Executive Director

A VITAL RESOURCE

Since 2015, Veterans

Leadership Program has

committed to making and

receiving referrals in

PAServes. The platform has

changed the way they have

delivered services.

REQUESTS RECEIVED IN

9 SERVICE CATEGORIES

% OF TOTAL

REQUESTS

Money Management 37%

Housing & Shelter 33%

Employment 25%

Other Categories 5%

COMMITTED TO

SERVING CLIENTS

BETTER…

561Referrals

Created

446Referrals

Recieved

THEY ARE WORKING TO EXPAND THE

NETWORK AND DEEPEN IMPACT

THEY HELP BRING THE NETWORK TO

ITS FULLEST POTENTIAL

OPERATION

TROOP

APPRECIATION

A NETWORK PILLAR

From the time they joined the

network in early 2016,

Operation Troop Appreciation

became an integral part of the

success of the network, using

the platform to manage all of

their service delivery.

COMMITTED TO

SERVING CLIENTS

BETTER…

1622Requests

Closed

Monica Orluk

CEO

55

332

0

50

100

150

200

250

300

350

400

0 1 2 3 4 5 6 7 8

# C

los

ed

Re

qu

es

ts

Quarter

98%of Requests

Resolved

EACH PROVIDER PLAYS A PART IN

IMPROVING SERVICE DELIVERY

A NEW CHAMPION

In recent months, the

network's "home"

organization, Pittsburgh

Mercy, has committed to

making more referrals and

utilizing the full diversity of

what the network has to offer.

PITTSBURGH MERCY

INTERVENTION

DEPARTMENT

Bill Sorrels, M.Ed.

Prevention Intervention

Specialist

COMMITTED TO

SERVING CLIENTS

BETTER…

40Referrals

Created

9 Service Categories

7 Network Organizations

18 Referrals Created in Q8

…AND 47 MORE REGISTERED PROVIDERS

COMPOSE PASERVES-GREATER PITTSBURGH

Service Providers Registered

The commitment of network providers to the mission leads

to more referrals in and out of the network to better serve.

33Q2

42Q4

Q6

51Q8

47 51Currently, there are

providers in the

network 28

26

27

21

Q7 & Q8

Q5 & Q6

Q3 & Q4

Q1 & Q2

78% of all

providers

have made or

received a

referral since

launch.

2 providers in the network – the VA and VLP – have

made over 500 referrals to date!

Providers Making or Receiving Referrals


Right Service










clients through the


knowledge exchange

network.

Our outcomes are

continuing to show


more timely and



board.

HOW DO WE BUILD IMPACT?

OUTCOMES ARE SHOWING THAT

THE COMMUNITY IS

COORDINATING SERVICES

TIM IS OFFERED A JOB

4 EMPLOYMENT REFERRALS

3 IN-NETWORK ORGANIZATIONS

1 OUT-OF-NETWORK ORGANIZATION

3 MONTHS OF ONGOING CARE COORDINATION

TIM WAS HIRED BY ONE OF THE

NETWORK ORGANIZATIONS

HELPING HIM FIND EMPLOYMENT.

HE IS CURRENTLY THE CLIENT

ASSISTANT AT VETERANS

LEADERSHIP PROGRAM.

WE SEE OUTCOMES LIKE TIM’S EVERYDAY.

Outcomes are key

ACCURACY

SPEED

The client receives the service that

aligned with their initial need due to

the data-driven nature of the

platform and the referral network.

The client receives the service

quicker than they ever had before

because of the tight provider

network and the easy-to-use care

coordination system.

THE CORNERSTONE OF

PASERVES-GREATER PITTSBURGH

IS AND ALWAYS HAS BEEN:

THE RIGHT SERVICE, QUICKER.

Speed & Accuracy

27

6

14

19

6

10

35

10

21

0

5

10

15

20

25

30

35

40

3 4 5 6 7 8

Overall Individual & Family Support Housing & Shelter

SPEED AND

ACCURACY GO

HAND IN HAND

The network ensures that the

client receives accurate and

targeted care, more quickly.

7Days to Match a

Referral to a

Provider

5Days to Match a

Referral to a

Provider

Q4

Q8

Median Service Episode Length (days)

Accuracy

55

60

65

70

75

80

85

90

95

100

0 2 4 6 8

% o

f C

losed

Serv

ice R

eq

uests

Res

olv

ed

Quarter

Overall Individual & Family Support Housing & Shelter

ACCURACY IS

THE REASON

WHY THE

MODEL

WORKS

84% of service requests

are resolved by the

network, allowing more

veterans, TSMs, and

family members to obtain

their desired service.

78%

96%

72%

64%

67%

87%

OUR NEW PLATFORM

2. OUR IMPACT

Robust Reporting on

Service Level & Clients

Better Representation

of Programs/Eligibility

Closed Loop Referrals (create a referral who it gets assigned to,

progress of their work, & outcome)

More Visibility(see the cases/referrals for your clients, even if

they are not assigned to you)

In mid-November 2017, with

IVMF, Unite US, Accenture, and

the support of the Coordination

Center, PAServes-Greater

Pittsburgh providers were

retrained and the network was

fully migrated onto an upgraded

platform (V3).

V3 has better visibility,

reporting, and transparency

allowing for better care for

veterans, service members,

and their families.

WE RECENTLY LAUNCHED ON A NEW

PLATFORM VERSION. WHAT DOES THIS MEAN?

WHAT’S THE OLD WAY?

CLOSING THE LOOP ON REFERRALS

Version 2

BETTER WAY OF SERVING

CLOSED LOOP REFERRALS

Version 3


LOW VISIBILITY

Version 2


IMPROVED VISIBILITY & VIEWING PERMISSIONS

Version 3


PROGRAMS

Version 2


PROGRAMS

Version 3

Choosing a

ProgramSetup and Display of a

Program


REPORTING

Version 2


REPORTING/DASHBOARDS

Version 3

PASERVES HAS TRANSFORMED THE

WAY GREATER PITTSBURGH CARES

FOR ITS MILITARY-CONNECTED

MEMBERS AND THEIR FAMILIES

AFTER TWO YEARS

EFFORTS AND INSIGHTS THAT WERE ONCE

ELUSIVE, ANECDOTAL, AND ISOLATED ARE NOW

CLEAR, MEASURABLE, AND COORDINATED,

INCREASING OUR COMMUNITY’S CAPACITY TO

UNDERSTAND INDIVIDUALS’ NEEDS AND – MOST

IMPORTANTLY – HOW THOSE NEEDS ARE

CONNECTED TO ACTUAL OUTCOMES

WHAT ARE OUR GOALS

FOR 2018?

WHERE ARE PASERVES

AND AMERICASERVES

GOING NEXT?

3. LOOKING

FORWARD

BECOME A

V3 POWER

USER

INCREASE

PROVIDER

ENGAGEMENT

PARTICIPATE

IN YOUR

LOCAL CoP

Impact

TO SERVE OUR COMMUNITY BETTER…

WHAT ARE OUR GOALS FOR 2018?

CREATE A

REFERRAL

ACCESS THE

DASHBOARD

PROVIDE

FEEDBACK

V3 Power User

Work through the new platform to create a referral

and track that referral across the client life cycle

Use the network dashboard to get a sense of

insights and service demand in the network

Let us know if you need additional training or

have any questions on the new software!


BECOME A V3 POWER USER

MAKE SURE THE

RIGHT USERS AT

YOUR ORGANIZATION

ARE TRAINED

TRY REFERRING AT

LEAST ONE CLIENT

INTO THE NETWORK

BEFORE 2018!


INCREASE PROVIDER ENGAGEMENT

Provider Engagement

SCHEDULE A TIME TO

TALK TO OR MEET

WITH YOUR CARE

COORDINATION TEAM


PARTICIPATE IN YOUR LOCAL CoP

Local CoP

Tailored to the needs of the

community, may include

provider presentations,

network findings/updates,

peer consultation

CALL AGENDA

Monthly dashboard with

local breakdown of speed,

accuracy, and volume

SUPPORTING ANALYTICS

All Network

Coordinators and

Network Providers

locally

WHO ATTENDS

IVMF lead and CC

lead co-facilitate

WHO FACILITATES

Once per month on a

regular cadence

WHEN

1. Convert more providers in

the network to active users

2. Offer providers valuable

information that will help

them improve their practice

GOALS

OUR GOAL: BRING PASERVES

INTO OUR BROADER COMMUNITY

OF PRACTICE EFFORTS

ZOOMING OUT…

WHERE ARE PASERVES AND

AMERICASERVES GOING NEXT?

IN ADDITION TO THE LOCAL CoP, WE ARE BUILDING OUT

REGIONAL AND NATIONAL COMMUNITIES OF PRACTICE – CALLED

PRACTICE360 – AS WELL AS OFFERING ADDITIONAL INSIGHTS AND

SUPPORT TO FURTHER ARM OUR PARTNERS WITH THE PROPER

TOOLS TO COORDINATE CARE.

WHAT WILL PRACTICE360 LOOK LIKE?

National CoP

LOCAL COP

Composed of local CC

and providers

REGIONAL COP

Composed of all regional

coordination centers (e.g.

Carolinas CoP)

NATIONAL COP

Composed of all national

network coordination

centers and providers

Best Practices Sharing

Analytics/Reporting Lessons Learned

INSIGHTS

Powered by the IVMF Research & Evaluation Team

GOALS

Communicate data in an interactive, flexible way

Provide more tools to help you collaborate and coordinate care

Illustrate the evolution of networks over time

Pinpoint and share best practices

FIRST OFFERING

AmericaServes Insights Dashboard

The first public, dynamic dashboard that allows you to monitor

growth and key performance indicators, identify trends across

networks, and observe the impact of our work.

SUPPORT

GOALS

Continue on-the-ground support of networks

Provide more training, materials, and offerings

NEXT STEPS

Next Steps

ARE YOU A PROVIDER OR

PARTNER?

Stay tuned for

information about the

first Local CoP call

SUBMIT A REFERRAL FOR YOUR CLIENTS!

Most importantly, take steps

to be even more active in

this network

VISIT OUR REVAMPED WEBSITE!

Visit the new dashboard

and read our newest

blog entries

1 2 3

THANK YOU AND CONGRATULATIONS!

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