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How Analytics Transform a Health Home Model: Contra Costa Develops a Predictive Model for Their High Utilizer Population


The team for Contra Costa Health System’s (CCHS) Safety Net Analytics Program (SNAP) had a clear goal in mind: use data to predict and address the needs of CCHS’s most high-utilizing, vulnerable patients. Meeting these high utilizers’ needs requires a range of providers to coordinate both their services and the patient data that accompanies those services. This case study details the steps CCHS’s SNAP team took to strengthen their data analytics capabilities to realize this vision, and outlines key takeaways for what made their project a success.

SNAP, implemented by Center for Care Innovations and funded by California Health Care Foundation, launched in November 2014 to increase the data analytics capabilities of health care safety net organizations to strengthen and improve patient care. The 14-month, cohort-based pilot provided a comprehensive set of supports to 20 organizations including learning sessions (webinars and in-person day-long conferences), individualized coaching, homework and planning tools, networking and financial support.

Resources, tools and instructional content from the Safety Net Analytics Program have been brought together as a video learning series, Building a Data Driven Culture, in addition to publications based on our evaluation findings: