Her organization is working with the Camden Coalition Health Information Exchange (HIE) to share patient data with social service agencies and the county jail.
“Getting social service agencies to become more involved is very important, especially with an underserved population like ours,” Bascelli says. “We are trying to get their diabetes or hypertension under control, which is virtually an impossible task when someone is not housed. It is a ridiculous thing to be talking to them about when they are scrambling for basic shelter.”
Health systems are becoming increasingly aware that social determinants of health (SDoH) can have as much impact on patients’ health as the type of care they receive from provider organizations. Therefore, population health improvement initiatives are relying on closer collaborations with the healthcare and human services sectors.
The focus on SDoH also requires that data flows across sectors that aren’t accustomed to collaborating. Most physicians are familiar with HIE organizations, which share lab results and orders with hospitals and other providers.
But several regions of the country are independently expanding their efforts to create community information exchanges (CIE). These CIEs, some created with support from the Robert Wood Johnson Foundation, link data and facilitate online referrals among medical providers and social service agencies involved in housing, food services, transportation, and corrections.
For example, physicians using the Camden Coalition HIE can be notified when their patients receive care in the jail’s medical system. Most of these efforts are just getting underway in 2019, starting with federally qualified health centers (FQHCs) and Medicaid accountable care organizations (ACOs). After working through governance and patient consent issues, the founding organizations are now turning to how physician offices will use the CIEs and what types of social determinant data physicans want to see.
Initially, the Camden Coalition started in 2010 to focus on helping social service agencies get access to some medical data. Once they had medical data flowing to social services, the next logical step was for clinicians to be more aware of social challenges their patients are facing.
“For the patients our care teams serve, their medical complexities are often related to their social needs,” says Christine McBride, program manager of Camden Coalition HIE. “We are documenting those connections to social service agencies in our HIE to make sure it is not just one social worker who knows the patient is experiencing homelessness, but also the nurse, the physician, and the community health worker.”
Treating the whole person
Perhaps the most ambitious efforts to create a more holistic view of patients are taking place in California. The state’s Medicaid program, Medi-Cal, is working with 25 counties to pilot an effort called Whole Person Care to coordinate health, behavioral health, and social services.
The counties are starting to share data and coordinate care for vulnerable Medi-Cal beneficiaries who have been identified as frequent users of multiple systems with persistently poor health outcomes. All counties are deploying relatively new technology platforms, usually from startup companies focused on this market, to allow previously siloed organizations to share data, create shared care plans, and evaluate the progress for both an individual and the population.
In Marin County, the Whole Person Care program is using a technology platform to provide physical and mental health data to social service agencies and deliver SDoH data back to a clinic where nurses and care coordinators can review the information.
The program has intentionally not yet incorporated physicians, says Ken Shapiro, director of the county program. “We know how valuable physicians’ time is,” he explains. “We have a phased roll out. Case managers and social workers are already using the platform. We want to get critical mass of care coordination nurses to use the system, work out the bugs, and work up the chain to the physicians.”
Care teams that include healthcare providers and social workers can use the platform to message each other, says Shapiro, who describes it as similar to having a discussion on Slack, the cloud-based collaborative work platform. Participants can begin a conversation about a patient, and the rest of the care team can see it. If a particular provider is mentioned, she will get notifications sent directly to her inbox.
“It has been a game changer for social service providers and community clinics to have this awareness and connection to other providers across the continuum,” he says.