– With the industry’s growing awareness that the social determinants of health have a considerable impact on patient health, more organizations are leaning on community health partnerships to address patient needs.
But bringing together those multiple stakeholders can be challenging, especially when an organization has no digital mechanism to back it up, found Ellie Zuehlke, the director of Community Benefit & Engagement at Allina Health.
“To make things feasible in a large healthcare system, across all of these different sites, with different staff, using different resources, technology is a really important piece,” Zuehlke told PatientEngagementHIT.com in a recent interview.
And that technology piece becomes even more important considering Allina Health is an Accountable Health Communities model participant. The program, launched by CMS in 2017, aims to understand how healthcare organizations can address the social determinants of health in high-needs patients.
CMS issues a payment to cover the infrastructure and staffing needs for participant organizations, and in return hospitals and health systems work to connect patients with certain social risk factors to community resources.
That’s a tall order for Allina’s providers, who Zuehlke said largely lacked the tools to connect their patients to community services. Although the health system has a long history of leveraging community relationships as a part of its population health management plans, providers didn’t have access to any of those resources.
“Our primary care leaders were saying, ‘you know, we know these social factors are really getting in the way of our ability to support our patients in achieving the health outcomes that we all want,’” Zuehlke reported. “Can’t we apply some of the community health thinking and community health approaches for our own patient population? Can you give doctors these tools internally?”
Zuehlke and her team wanted to lean on technology to solve this problem. Although the health system is admittedly still in the throes of its digital transition, Zuehlke knew that going digital was going to be the best solution for streamlining community health within the clinician office.
And she was right.
After tapping NowPow, a health technology aimed at digitizing the community health referral process, providers said it was easier to connect their patients with local resources to address the social determinants of health.
In her role, Zuehlke said the technology made it easier for the organization to know what community resources were out there and for patient engagement and navigation workers to make inroads with those resources.
The process at Allina works like this: A patient will present at one of the health system’s 78 different care delivery sites across the care continuum. If the patient is covered by Medicare, Medicaid, or is dual-eligible, a front office worker will give them a paper intake survey aimed at collecting social demographic data about the patient.
Allina hopes to digitize those patient intake surveys soon, but for the time being it hires medical assistants to input information into the EHR, which is then directly transmitted into their community referral system.
“For all patients who identify at least one need – food, housing, transportation, interpersonal safety, and difficulty paying utility bills – the tool generates a tailored list of community resources for the patient,” Zuehlke explained. “That is based on the patient’s screening results that we’ve just entered into the EMR.”
That information is also put into the context of a patient’s demographic data that’s in the EHR, such as their home address.
“It essentially is a brochure, but it’s a tailored brochure,” Zuehlke added. “So, it’s specific to resources that are close to where the patient lives. And if they’ve only identified needs in one area then they don’t get an onslaught of information, they get information that is very specific to the need that they identified.”
And some patients who are at higher risk for health complications and social health issues qualify for further services, too, Zuehlke said.
“In the CMS model, there is an additional intervention for patient navigation,” she said.
Patients who self-identify as needing patient navigation or who have been in the emergency department two or more times in a year qualify for these services.
“It is more of a traditional social work or community health worker intervention,” Zuehlke explained. “We’re approaching patients early, we follow the person who helps them to develop a plan. And then we’ll work with them for up to a year to resolve those needs.”
For that subset of patients, social workers actually help them decide which social services they may access or if the patient is in need of other resources. Social workers will also connect with the community group, confirm a patient’s appointment with the community group, and follow up with the group after the patient was supposed to have visited.
None of this would have been possible without the use of technology, Zuehlke offered anecdotally, noting that the health system doesn’t yet have numbers to back up the tool’s success. Nonetheless, the benefits have been tangible, Zuehlke said.
For one, Allina would not have been able to help providers communicate about social needs with their patients. Technology has helped providers know what types of resources are out there to help their patients, which has empowered providers to broach the subject during encounters.
“What the technology did by producing this automatic, tailored list of community resources, it made it feasible, in the context of primary care visit, where you’ve got to get everything done and you don’t have additional time or resources, to be able to ask those questions and then provide a response,” Zuehlke stated. “That has been an incredible facilitator for culture change.”
Technology has also helped Allina further build out their relationships with community groups. As noted above, the health system had some preliminary relationships with social services groups, but they were limited.
Technology has helped make those relationships more meaningful by easing the burden on both providers and social services groups.
“We did some discovery work last fall, really understanding both from the health systems side and also from our community partner’s side, what’s going to be really important in building and maintaining these relationships,” Zuehlke shared.
What they found was that trust and communication were essential to a healthy relationship between health systems and community partners.
And while building that relationship is an interpersonal mission that requires a deep understanding of health system and community priorities, technology has supplemented Allina’s efforts. It has made it easier for providers to understand what a social services group offers and to ease referral and intake burden off of that group.
“This is newer for us, but we’re really excited about how that really will help facilitate partnerships and reduce some of the burden especially, on our community partners,” Zuehlke said. “We’re a very phones-, fax-, email-based system and so we’re really hoping that the technology is going to help facilitate some of those connections.”
Of course, the future of community health is filled with more questions than answers, Zuehlke acknowledged. Payment, for example, is an issue that continues to crop up and stump policymakers.
“Cost and payment is a broader policy conversation and really a conversation we need to have as a community,” she noted. “This opportunity to try something new in terms of facilitating relationships has brought a lot of different partners to the table who been at the table before. We need healthcare sitting with social services or community-based organizations.”
If she had to guess, Zuehlke predicts payment is going to be a blended model that combines philanthropy, public funding, and in payer contributions where relevant.
But before the industry can fully hammer out the details of payment protocol for social determinants of health, it must establish the evidence base.
That is where organizations like Allina are making their contributions, Zuehlke said.
“There is a lot we don’t know about community health but there is a lot of interest right now in actively figuring it out,” she noted. “One of our key contributions to the puzzle, and part of why I think CMS is doing the Health Communities model, is that even demonstrating whether this approach of community health and social determinants will work.”
And as health systems like Allina continue to explore the subject, it will be essential for them to prioritize collaboration with different industries.
“The social determinants thing, there is nothing new about it,” Zuehlke concluded. “It’s sort of the basis of public health. But what has been exciting to me and where I think technology has made such a difference, is bringing other stakeholders to the table in this really complex question.”
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