SOCIAL DETERMINANTS OF HEALTH ARE PART OF THE PUZZLE
Over the past few years, there has been vocal realization that social determinants of health are indeed a critical part of the total health puzzle, not only from the perspective of the patient’s health betterment, but also from the economic implications of reducing avoidable utilization. Policy makers are pushing forward with programs to address this realization:
CMS is aggressively promoting Its Accountable Health Communities Model
New York State is making an $8 billion investment in the Delivery System Reform Incentive Payment (DSRIP) program to promote community-level collaborations with the intent of reducing avoidable hospital readmissions.
Nevertheless, most healthcare providers are hesitating on what concrete steps they should take to extend patient care coordination, improve total care, reduce avoidable utilization, and track patient care outcome visibility.
FIRST GENERATION “REFERRAL AND COMMUNITY NAVIGATION” TECHNOLOGIES
Over the past 3 years, several new and reinvented healthcare tech providers have come to market to capitalize on this opportunity and provide the systems healthcare providers need.
Many of these solutions; however, are fundamentally flawed. Instead of creating platforms that are designed to make the patient journey and data-access the focal point of their solution, they merely digitize “yellow pages” of service providers into curated e-directories and augment them with bi-directional referral tools aimed at escorting patients out of the clinical realm.
This approach to addressing the social needs of individuals is inadequate and overly transactional, prioritizing the referral over the patient, the health journey, and health outcomes. Sadly, health continuums miss out on the opportunity to take a 360-degree view of the whole person and effectively cater to their multiple needs: social, clinical and behavioral. Instead, they are narrowly concerned with the following:
Was the referral made?
Was the referral accepted and closed?
Did the appointment occur?
Unfortunately, whether a referral is made or accepted or an appointment confirmed does not shed any light on the whole person’s needs nor does it provide visibility into their health journey, their broader social determinants of health, and patient care outcomes. This approach cannot track what happens to the patient once they leave the four walls of the hospital and whether their complex needs were addressed.
WHAT HAPPENS NEXT?
Since these first generation referral tools cannot address the individual patient’s multiple co-occurring needs, track their total health journey, and report structured outcomes at scale- health systems should look beyond the referral and build accountable community coordinated networks. By addressing patient’s social determinants beyond the referral and prioritizing the patient providers can can effectively coordinate care, track the patient journey, report patient outcomes at scale, and most importantly improve health outcomes. Unite Us provides technology and a change management curriculum to effectively build and implement these coordinated networks.
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