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A Complete System
                                      Of Care Management




   The program and case management enterprise system for
the new generation of maternal child and family health programs.

      WFS redefines “Business As Usual!”.
Life Course focused system that manages and tracks the
interaction of individuals and families with programs and
services from birth over the course of their lives.

A single program can stand alone or coexist with other programs as a collaborative
enterprise while providing common intake paths, managing services and activities
in complex family situations, common family support plans as a family-centered
process. WFS reduces duplication of services, increases knowledge of client risks
and needs, reduces the chance of clients “falling through the cracks”, streamlines
the process of delivering services and contributes to economy and efficiency.


                WFS is a powerful suite of tools and resources that manage
                multiple aspects of maternal child and family health programs
                and case management delivery systems in a drill-down
                capacity from a “lead” perspective to individual providers and
                case worker levels on any capacity.
Everything Can Be Connected
                                                    2
                                                Families connect to POC,
     1                                             Outreach, Groups
   WFS Program, Case and
  Family Management System




         Healthcare,                                    Inter Agency
           EHR                                           Operations

      5                  Information, Research,         3
                        Evidence Sharing & Policy
                         4
A Complete System of Care
                              Provide Direct
                                 Services
     Manage Programs
     and Organizations      Refer and Follow
                              Up Services
      Central Referral
     and Intake Process     Screenings, Tools
                            and Assessments
     Manage Contacts,
     Outreach, People         Direct Client or
                            Group Participation
    Engagement, Home
                             Invoicing, Billing,
     and Other Visits
                            Time Management

                               Reporting,
                              Accountability
The Benefits

As a Complete System of Care Well Family:



   ► decreases the duplication of services

   ► increases knowledge of client risks and needs

   ► reduces the chance of clients “falling through the cracks”

   ► streamlines the process of delivering services

   ► contributes to economy and efficiency
WFS is activity, risk factor, event and timeline driven, offering interactive calendars,
extensive ticklers and other tools that manage program requirements, benchmarks,
milestones, services and significant events in care such as visits, developmental
aspects, immunizations, assessments, and more.

WFS includes comprehensive contact and encounter management tools. WFS is
ideal for home visiting, clinical and other contact-based service programs.

WFS assesses risks, builds a care plan and a customizable interactive family support
plan.

WFS includes many evaluation and assessment tools, surveys, home safety
inspections and unlimited measures, screening tools and other assets.

WFS manages group activities and client participation in groups such as parenting
classes and other activities.

WFS has an extensive services referral component that allows referred services to
be tracked and the ability for service providers to complete the referrals in WFS.

WFS optional features include the ability for individuals to participate in profiles and
“self refer” to WFS service providers. WFS can be connected to the Family Resource
Engine (FRE), a 211 style tool that connects a broad range of community resources
to the system. WFS is also a cost tracking system that connects services provided to
billing codes and payment systems.



                                   WFS Basics
People, Program, Services and Communities
           What is the WFS equation?




            + relationships
          X programs + services

                  TIME = WFS



  The total Well Family experience is:

  • The relationship of people and families
  • Their interaction with programs and services
  • Their interaction with the community

             OVER TIME!
It IS ALL Connected


There are “binders” that
connect people, families and
relationships to each other




                                BIOLOGICAL
                                 RELATIVES
                                  LEGAL
                                   CULTURAL
It IS ALL Connected




                 And a community is the sum total of all of
                  the programs, services, resources and
                  assets available to people and families.




Contacts
                                                                Services
           Engagements
                         Activities   Assessments   Referrals
It IS ALL Connected




   A Family is a Social Network!
A community is a network of families,
     programs and services!
It IS ALL Connected




Well Family
IS ABOUT
 PEOPLE
Well Family System as a Single Program


                       Workflow and process
                        specific to program
                            and users
Well Family System in a
Multiple Program Environment     Prevents duplication of
                               services, increases positive
                                  economics, provides
                                    continuum of care
Multiple Program Model With MIECHV




The Virginia Model   – Stage 1     Two MIECHV Options
72 RM sites statewide                 Full WFS
3 Fed HS Projects                     MIECHV Lite
MIECHV programs
(NFP, PAT, HF, more to be added)
MIECHV




► Minimized WFS just for MIECHV benchmark data
► Identifies and accepts clients from all EB programs

► MIECHV clients part of WFS population

► Hands on data entry or electronically matched to WFS

► Specific reports for benchmarks, HRSA, etc.
Basics

WFS functions on the principle that all programs more than likely
share the same basic operational functions but may have a
different target population, program, or outcome focus.


      ► Referral, Intake, Triage, Enrollment
      ► Outreach – Contact Management

      ► Engagement – Home, Clinic, Other Visits

      ► Direct Services Provided

      ► Referred Services – Follow Up

      ► Screenings, Evaluations, Assessments, Tests, Surveys
As a Continuous Care Management System WFS
     Navigates People Across Programs Over Time
                           WFS smart intake process assesses
                          the past and current client conditions.

Who are you?
                      I am a 24 year old married female with 2 children.


Have you been in WFS before?      Yes, I was in an ICC program in 2008.


Why are you here today?        I am pregnant

                                                                       Prenatal
                                                                        Intake
                                                                           &
 Directs the participation path based on                                Case
Intake Type and program requirements.                                 Management
Each New Program Participation Places the Client
  on the Appropriate Path of Care and Management

                            Women’s Health Questionnaire
                                Case Management


                                   Prenatal Intake
                                Prenatal Assessment
                                 Case Management


                            Women’s Health Questionnaire
                                Case Management



                                 Case Management


                                    Infant Screen
  Next step processing           Infant Assessment
                                 Case Management
and care management is
 determined by specific
 program requirements.
The Continuing Plan of Care and Family Support Plan
          Are Built on Risks, Needs and Previous Services
    Info at intake and during risk assessment is
 analyzed and triggers needs in several categories.

                                     Which automatically builds a POC & FSP


PHYSICAL-MENTAL HEALTH                CATEGORY                    ITEM                      ACTION

                               Physical and Mental Health      Dental Issues         Refer to Dental
                               Services
  EARLY DEVELOPMENT                                           No Infant Care        Enroll with Pediatrician
                               Safe & Nurturing Environment    No Permanent Home     Housing Assistance


  SOCIAL - EMOTIONAL           Economic Stability             Father Not Working     Refer to WIC
                                                                                   Job Training


 SPIRITUAL FOUNDATION
                                        A Plan of Care is initiated and The
  SAFE ENVIRONMENT                   Family Support Plan provides a starting
                                     point for determining a path of care and
  ECONOMIC STABILITY                 can be shared across programs and can
                                      be part of the family history over time.
Typical Program Ticklers

Smart work and process flow ticklers vary from program
   to program and are also different for user roles.
Reporting And Data

       Accountability, Reporting and Access To Data



► System generated reports

► SQL Reporting Services

► Scheduled download of WFS database

► Data List Tools
Reporting And Data
         System Generated Reports
WFS provides a variety of reports that are directly accessible from the system. Generally these
reports usually are in the areas of demographics, services, engagement, retention, outcomes and
performance measures etc. Also HRSA, Title V, benchmark and other “funder” based reports are
provided from the online WFS.
                                                                Example
                    Typical Report Types
Reporting And Data
         System Generated Reports
WFS provides a variety of reports that are directly accessible from the system. Generally these
reports usually are in the areas of demographics, services, engagement, retention, outcomes and
performance measures etc. Also HRSA, Title V, benchmark and other “funder” based reports are
provided from the online WFS.
                                    Typical Report Types

                  Outcomes                                    HF Sample

                Performance                               Program Report
                                                               Example 1
            Typical Operations
                                                               Example 2
                   Example 1
                                                               Example 3
                   Example 2
                   Example 3                               Demographics

               Case Changes                                    Services
Reporting And Data
SQL Reporting Services




    SQL Server Reporting Services (SSRS) is a server-based report
    generation software system from Microsoft. It is used to prepare and
    deliver a variety of interactive and printed reports directly from the
    WFS database. It is administered via a secure web interface.
    Reporting services features a web services interface to support the
    development of custom reporting applications. SSRS is on par with
    Crystal Reports and other business intelligence tools.

                              Example
Reporting And Data
SQL Reporting Services
Reporting And Data
Download of WFS database




         A Well Family System database “copy” can be transferred
            securely (SFTP) on any schedule (daily, weekly, monthly,
            etc.). This is your copy of the database, and it enables
            two valuable options:
         1. Broadens the scope of business continuity so that your IT
            staff has a recent backup copy of your program data.
         2. Allows your data analysts their own copy to drill into, put in
            a cube, or import into SAS, SPSS, etc.
Reporting And Data
          WFS Data List Tool
Data List is a WFS tool that allows the users to build custom data sets. Typically data Lists are used to
manage clients, services, special groups, etc. but are not limited to the type of data sets that can be
arranged.
As a Complete System
        of Care Management

WFS enables families, organizations
and communities to be more efficient,
   accountable and successful in
  delivering quality programs and
  services that make a difference.




                        gobeyondmch.com
                 email: info@gobeyondmch.com

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Well Family as a Life Course Focused, Family Fentered System by Go Beyond MCH

  • 1. A Complete System Of Care Management The program and case management enterprise system for the new generation of maternal child and family health programs. WFS redefines “Business As Usual!”.
  • 2. Life Course focused system that manages and tracks the interaction of individuals and families with programs and services from birth over the course of their lives. A single program can stand alone or coexist with other programs as a collaborative enterprise while providing common intake paths, managing services and activities in complex family situations, common family support plans as a family-centered process. WFS reduces duplication of services, increases knowledge of client risks and needs, reduces the chance of clients “falling through the cracks”, streamlines the process of delivering services and contributes to economy and efficiency. WFS is a powerful suite of tools and resources that manage multiple aspects of maternal child and family health programs and case management delivery systems in a drill-down capacity from a “lead” perspective to individual providers and case worker levels on any capacity.
  • 3. Everything Can Be Connected 2 Families connect to POC, 1 Outreach, Groups WFS Program, Case and Family Management System Healthcare, Inter Agency EHR Operations 5 Information, Research, 3 Evidence Sharing & Policy 4
  • 4. A Complete System of Care Provide Direct Services Manage Programs and Organizations Refer and Follow Up Services Central Referral and Intake Process Screenings, Tools and Assessments Manage Contacts, Outreach, People Direct Client or Group Participation Engagement, Home Invoicing, Billing, and Other Visits Time Management Reporting, Accountability
  • 5. The Benefits As a Complete System of Care Well Family: ► decreases the duplication of services ► increases knowledge of client risks and needs ► reduces the chance of clients “falling through the cracks” ► streamlines the process of delivering services ► contributes to economy and efficiency
  • 6. WFS is activity, risk factor, event and timeline driven, offering interactive calendars, extensive ticklers and other tools that manage program requirements, benchmarks, milestones, services and significant events in care such as visits, developmental aspects, immunizations, assessments, and more. WFS includes comprehensive contact and encounter management tools. WFS is ideal for home visiting, clinical and other contact-based service programs. WFS assesses risks, builds a care plan and a customizable interactive family support plan. WFS includes many evaluation and assessment tools, surveys, home safety inspections and unlimited measures, screening tools and other assets. WFS manages group activities and client participation in groups such as parenting classes and other activities. WFS has an extensive services referral component that allows referred services to be tracked and the ability for service providers to complete the referrals in WFS. WFS optional features include the ability for individuals to participate in profiles and “self refer” to WFS service providers. WFS can be connected to the Family Resource Engine (FRE), a 211 style tool that connects a broad range of community resources to the system. WFS is also a cost tracking system that connects services provided to billing codes and payment systems. WFS Basics
  • 7. People, Program, Services and Communities What is the WFS equation? + relationships X programs + services TIME = WFS The total Well Family experience is: • The relationship of people and families • Their interaction with programs and services • Their interaction with the community OVER TIME!
  • 8. It IS ALL Connected There are “binders” that connect people, families and relationships to each other BIOLOGICAL RELATIVES LEGAL CULTURAL
  • 9. It IS ALL Connected And a community is the sum total of all of the programs, services, resources and assets available to people and families. Contacts Services Engagements Activities Assessments Referrals
  • 10. It IS ALL Connected A Family is a Social Network! A community is a network of families, programs and services!
  • 11. It IS ALL Connected Well Family IS ABOUT PEOPLE
  • 12. Well Family System as a Single Program Workflow and process specific to program and users
  • 13. Well Family System in a Multiple Program Environment Prevents duplication of services, increases positive economics, provides continuum of care
  • 14. Multiple Program Model With MIECHV The Virginia Model – Stage 1 Two MIECHV Options 72 RM sites statewide  Full WFS 3 Fed HS Projects  MIECHV Lite MIECHV programs (NFP, PAT, HF, more to be added)
  • 15. MIECHV ► Minimized WFS just for MIECHV benchmark data ► Identifies and accepts clients from all EB programs ► MIECHV clients part of WFS population ► Hands on data entry or electronically matched to WFS ► Specific reports for benchmarks, HRSA, etc.
  • 16. Basics WFS functions on the principle that all programs more than likely share the same basic operational functions but may have a different target population, program, or outcome focus. ► Referral, Intake, Triage, Enrollment ► Outreach – Contact Management ► Engagement – Home, Clinic, Other Visits ► Direct Services Provided ► Referred Services – Follow Up ► Screenings, Evaluations, Assessments, Tests, Surveys
  • 17. As a Continuous Care Management System WFS Navigates People Across Programs Over Time WFS smart intake process assesses the past and current client conditions. Who are you? I am a 24 year old married female with 2 children. Have you been in WFS before? Yes, I was in an ICC program in 2008. Why are you here today? I am pregnant Prenatal Intake & Directs the participation path based on Case Intake Type and program requirements. Management
  • 18. Each New Program Participation Places the Client on the Appropriate Path of Care and Management Women’s Health Questionnaire Case Management Prenatal Intake Prenatal Assessment Case Management Women’s Health Questionnaire Case Management Case Management Infant Screen Next step processing Infant Assessment Case Management and care management is determined by specific program requirements.
  • 19. The Continuing Plan of Care and Family Support Plan Are Built on Risks, Needs and Previous Services Info at intake and during risk assessment is analyzed and triggers needs in several categories. Which automatically builds a POC & FSP PHYSICAL-MENTAL HEALTH CATEGORY ITEM ACTION Physical and Mental Health Dental Issues Refer to Dental Services EARLY DEVELOPMENT No Infant Care Enroll with Pediatrician Safe & Nurturing Environment No Permanent Home Housing Assistance SOCIAL - EMOTIONAL Economic Stability Father Not Working Refer to WIC Job Training SPIRITUAL FOUNDATION A Plan of Care is initiated and The SAFE ENVIRONMENT Family Support Plan provides a starting point for determining a path of care and ECONOMIC STABILITY can be shared across programs and can be part of the family history over time.
  • 20. Typical Program Ticklers Smart work and process flow ticklers vary from program to program and are also different for user roles.
  • 21. Reporting And Data Accountability, Reporting and Access To Data ► System generated reports ► SQL Reporting Services ► Scheduled download of WFS database ► Data List Tools
  • 22. Reporting And Data System Generated Reports WFS provides a variety of reports that are directly accessible from the system. Generally these reports usually are in the areas of demographics, services, engagement, retention, outcomes and performance measures etc. Also HRSA, Title V, benchmark and other “funder” based reports are provided from the online WFS. Example Typical Report Types
  • 23. Reporting And Data System Generated Reports WFS provides a variety of reports that are directly accessible from the system. Generally these reports usually are in the areas of demographics, services, engagement, retention, outcomes and performance measures etc. Also HRSA, Title V, benchmark and other “funder” based reports are provided from the online WFS. Typical Report Types Outcomes HF Sample Performance Program Report Example 1 Typical Operations Example 2 Example 1 Example 3 Example 2 Example 3 Demographics Case Changes Services
  • 24. Reporting And Data SQL Reporting Services SQL Server Reporting Services (SSRS) is a server-based report generation software system from Microsoft. It is used to prepare and deliver a variety of interactive and printed reports directly from the WFS database. It is administered via a secure web interface. Reporting services features a web services interface to support the development of custom reporting applications. SSRS is on par with Crystal Reports and other business intelligence tools. Example
  • 25. Reporting And Data SQL Reporting Services
  • 26. Reporting And Data Download of WFS database A Well Family System database “copy” can be transferred securely (SFTP) on any schedule (daily, weekly, monthly, etc.). This is your copy of the database, and it enables two valuable options: 1. Broadens the scope of business continuity so that your IT staff has a recent backup copy of your program data. 2. Allows your data analysts their own copy to drill into, put in a cube, or import into SAS, SPSS, etc.
  • 27. Reporting And Data WFS Data List Tool Data List is a WFS tool that allows the users to build custom data sets. Typically data Lists are used to manage clients, services, special groups, etc. but are not limited to the type of data sets that can be arranged.
  • 28. As a Complete System of Care Management WFS enables families, organizations and communities to be more efficient, accountable and successful in delivering quality programs and services that make a difference. gobeyondmch.com email: info@gobeyondmch.com