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Getting SDoH in Action Closing Referral Loops with AI assisted Care Management on a FHIR enabled Data Activation Platform

Aakanksha Saini
Mon 05 October 2020
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Although there has been significant progress in recognizing and addressing social determinants of health, many challenges remain. The biggest one being the ability to close referral loops which is an integral part of an SDoH solution. Hence, we envisioned and started developing an application for Community Resource Workers.  

Background story 

At Innovaccer, design thinking goes into everything that we create. We spent the first few months of this year talking to many social workers and community health workers along with assessing patterns in the referral outcomes to understand where patients were falling through the cracks. A few themes emerged from these conversations: 

Almost always, there are a few resources that have better outcomes. 

The referring organizations usually have personal relationships with them and know the individuals handling referrals at the other end. During our focus group sessions, we found out that most of the social workers did not have any level of collaboration with 70% of the community resources. Many such referrals fail because of unknown eligibility criteria and the unavailability of community resources. A close connection with 20 community resources is much better than a directory containing 10,000 programs. Everything else is just an email ID and one has no idea of who is at the other end.
The definition of a closed-loop referral is ambiguous amongst organizations.

Is handing out resource information to patients, hoping they will visit next week, and reminding them about it good enough? A closed-loop referral means that the social worker is able to assess and identify the most appropriate resource from multiple options, ensure that the patient is in agreement, get the engagement scheduled, ensure that the referral happens, and have some form of response back to show that the engagement happened and whether there is a scope of potential further collaboration. For a social worker who is dealing with new patients every day, it is arduous to carve out bandwidth and chase patients and community resources to verify this information. Hence, a lot of referrals remain open and are ultimately closed as “outcome unknown.”

Not many platforms have looked deeper into the problems of community resources who are at the frontlines of catering to patients' social needs.
Each and every connected resource is equally important in creating your army. A food bank would not have the same facilities available for its workers as the American Red Cross. Most of these resources have insufficient technical capacity and workforce. They possibly cannot make additional investments in supporting the technology that helps them close referral loops and need something that is handy, easy to use, and does not involve a learning curve for their volunteers who change every now and then.
 This is precisely why, in a desktop heavy healthcare world, Innovaccer has taken a mobile-first approach with its ‘InCare for Community Resources' application.  
 It is a workflow manager for community resources where they can receive referrals from multiple health systems, manage their appointments, and track the referral outcomes. Below is the high-level workflow that enables closed-loop referrals in our app ecosystem: 
 
1. Sign-up:
 
Community resources create their profiles on the application. Resources that are directly connected to our customers are listed on the InCare’s central resource repository called “Partner Resources” right away, whereas other independent resources who download the app from the App or Google stores are verified first so that social workers can rest assured that there is a legitimate person at the other end who is just as responsible for the patient’s social needs.
 
2. Electronic Referral Management:

Referral Creation
Social workers using the InCare web application can refer their patients to these partner resources. The referral contains patient information and social worker’s comments that help the resources understand the patient’s needs better along with the suggested appointment date.
 
Referral Acceptance: 
Community resources get a real-time push notification of the referral on their app. After assessing the referral, they can accept or reject it depending on their criteria. The change in the referral status goes back to the social worker as a notification. During the signup process, we push resources to create their profile in a way that the social workers are able to understand if they are the right resources for the patient, hence, the rejection rate with the app will be comparatively lower. 
 
Referral Tracking: 
All the accepted referrals are shown under the “Appointments” tab based on their appointment date so the resources can manage their daily workload and change the statuses of cases accordingly.

3. Bidirectional Communication:
Community resources and social workers can share their encounter notes with each other to discuss the case further and update each other of new developments.
 
4. Tracking Outcomes: 
Our dashboards provide actionable insights to improve the referral outcomes and address service gaps for every specific social need.
 
Sneak-peek into the app
  
 
       
Each story inspires a million others…  
“There was this woman who used to come to the clinic for her 7-year-old son’s Asthma treatment. I would see one or the other wound around her face every time. She always had new excuses under her sleeves. I could easily see through what was going on and would give her booklets of all the options she had. I hadn’t seen her in a long time, her son had been missing his appointments lately, so one day I decided to visit her place and check what had happened. When I went to the given address, they told me it was vacated long back and while the new occupants didn’t know the exact whereabouts, they mentioned the street name. It took a while before I could locate her. Perhaps she was much more comfortable in her surroundings so she told me her story. Her husband was an out of job alcoholic and she worked to support her family which was still not enough. On top of it, she had to face the wrath of every failed job interview. Somehow I convinced her to move to the Haven House Shelter for domestic violence victims. To see things through, I went to the shelter along with her so I could sleep peacefully at night. This is the part of my job that I just hate. I wish I could help all such people this way but I just cannot and it just sucks”  
 
A social worker I met at the Case Management Society of America conference last year. I don’t remember her name but her story stuck with me.   While technology cannot replace the human touch, I hope we are able to empower many more social and community health workers through this application.  
 
To learn more about how you can take your care management approach a notch above the rest by harnessing the true potential of your SDoH data, get a demo.  For more information, subscribe.

 
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