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How to Enable Holistic Care for Individuals – The Smarter Care Approach

How can agencies enable holistic and individualized care to citizens? This is the crux of the issue for improving social programs in the public sector. In today’s world, there are a variety of issues that come into play when providing social programs to those in need. It’s beyond just looking at lifestyle choices, social determinants and clinical factors – proper care revolves around looking at how these factors are interconnected and used to create a full view of the citizen.

There is power in connecting the dots, to improve services for citizens and organizational efficiency. I’ve seen this first hand, as I use to work at Syracuse Habitat for Humanity. Our office was located on the Near West side of Syracuse, one of the poorest neighborhoods in the country. There are literally blocks of homes that are boarded up and abandoned.

At Habitat, I interviewed dozens of homeowners and people in the community, and it was a privilege to get to know a lot of the people in the neighborhood. Many people were recipients of SNAP, Medicare, Medicaid and many other state and federal social programs. As I reflected back on my experience at Habitat and the community I worked in, I began to think about the importance of providing holistic care to program recipients, and the value it brings to organizations and citizens.

An anecdote that helps to process IBM’s Smarter Care approach is that one of our homeowners received in-home treatment for a disability. Their social worker should have the proper insights about everything related to the individual care. Although these insights would lead to improved care, often, this level of collaboration does not exist. Their caseworker should know about the prescribed therapy, medication and available government programs they qualify for. If these insights are not known, it’s not to any fault of the social worker, but more indicative of an organization not fully leveraging data to paint a full picture of the individual.

The solution to improve the wellness of the Habitat homeowner comes down to the Smarter Care approach. When I review the “Smarter Care” approach, the image that comes to mind is an ecosystem of care. Imagine the caseworker having the ability to see the full scope of the citizen, all the programs, medications, lifestyle insights, social determinants and anything that will help improve the wellness of the individual to provide a tailored care plan. These insights will come from removing data silos, reducing paper and increasing collaboration across government agencies and between sectors.

Those are the insights that Smarter Care powers. Agencies connect the dots and find value and meaning for various inputs, all helping to improve the wellness of a citizen, and the insights to a social worker. This idea of holistic care is foundational to IBM’s Smarter Care approach. Not only does a holistic approach to citizen needs improve services to citizens, it also can enable productivity gains for employees and lead to cost savings for an agency.

Importantly, this approach comes at a time when across the country, we have seen new communities of practice emerge and operate under unique partnerships. New delivery models, like public-private partnerships, have changed the way government provides assistance to those in need. Now, the ecosystem of care is more complex than ever before.


To fully define the care ecosystem of individuals, organizations must be sure they have developed and designed the proper IT systems to break down silos. The bottom line is that citizens deserve better, deserve more – and IBM’s Smarter Care is one way to push towards tailored, holistic care plans to improve the wellness of individuals, and communities.

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Profile Photo Ramona Winkelbauer

Pat, you see this: “When I review the “Smarter Care” approach, the image that comes to mind is an ecosystem of care. Imagine the caseworker having the ability to see the full scope of the citizen, all the programs, medications, lifestyle insights, social determinants and anything that will help improve the wellness of the individual to provide a tailored care plan. These insights will come from removing data silos, reducing paper and increasing collaboration across government agencies and between sectors.” as a benefit.

I’m afraid I see this more as “open citizen” than a beneficial “open government” program. Currently, the tax records/property listings are web enabled, so anyone who wants to look up my address can see how much I paid for my house and whether I am in arrears on my property tax payments, yet the (source) documents that (are supposed to) inform my representatives/legislators on the laws they are reviewing/passing are not available for public inspection/download nor, for the most part are the laws themselves —- frequently, what is open is the text of the law, while the background materials (enforcement mechanisms) are not.

Pat is unhappy that the social worker doesn’t (currently) see that a particular individual is taking Allergan when s/he is visiting her/him. I wonder if the individual isn’t afraid that a Social Worker will know her/his business when s/he shouldn’t and the possibility for the misuse/abuse/concatenation of the information collected.

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Profile Photo Kathryn David

Ramona, I definitely agree with you that there are privacy issues to be dealt with. Everything I’ve heard suggests that IBM is working closely with case workers to ensure Smarter Care is compliant with HIPPA and other regulations. I think the potential benefit of “no wrong door” could truly work wonders. I was recently in the hospital and my “roommate” was a homeless man with diabetes. He kept returning to the hospital because his advocates that helped him with housing did not have the knowledge to help him with taking his insulin. Smarter care could change that and ensure everyone is getting the care they need.

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