As healthcare executives place a greater focus on addressing social determinants of health (SDoH), it’s important to look at the key factors that can advance those efforts. Two of the most critical are: 1.) well-curated networks that connect payers, providers and health plan members with social care; and 2.) the technology that facilitates those connections.
Like most organizations, non-profits that address the social needs of communities’ most vulnerable residents are starting to make strides in embracing technology. Payers are collaborating with providers to ensure that data is being used to refer patients to those community-based organizations to make sure that health plan resources are being used wisely, with a focus on better health care—and health—for members.
In some parts of the country, community-based organizations (CBOs) and medical provider groups—with the support of the payers in those regions—are effectively collaborating through technology-driven referral platforms as members of the same team to bring social care and health care together. By doing so in the context of well-curated networks, their communities’ most pressing social needs―including food insecurity, interpersonal violence, transportation challenges and housing instability—people’s well-being and overall health begin to improve.
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But faxing information back and forth or sending patients off with a food pantry’s phone number on a sticky note and hoping they call may still happen all too often―even though we all agree that in the hyper-connectedness of today, it shouldn’t. If teenagers in North Dakota can strike up fluid conversations with peers in Mumbai, surely there must be a way for a physician to refer an individual to a food pantry with confidence the CBO will receive the message and confirm that the individual's needs have been met.
Virginia, there is a way for this to work
Modern, technology-driven platforms are available to facilitate referrals that address social needs, but they must possess key characteristics to achieve success. First, the platform must enable medical providers to connect individuals to social service organizations, such as behavioral health providers, benefit navigators, food pantries and workforce development agencies. Next, they must make it simple for these organizations to understand patients’ health statuses and how their social needs may be unique as a result. Finally, the systems need to have automated feedback that notify team members when patients receive services (and when they do not) so that appropriate action can be taken.
Just as importantly, referral platforms need to help CBOs and provider groups communicate effectively to address their patients’ needs and care plans in a unified way. Siloed technology can cause siloed processes and siloed decisions―increasing the risk that individuals could fall through the cracks between well-intentioned efforts to collaborate. Finally, these platforms must be capable of capturing the right information, based on claims data and information collected during the doctor or hospital visit, to measure the effectiveness of social interventions, including the extent to which interventions are producing desired health and financial outcomes.