Problem
Legacy Community Health (LCH) has integrated a patient-centered model of care for all individuals within their system, a model that promotes wellness beyond medical aid and has the potential to provide a structure that promotes independent and sustainable health practices. Furthermore, they have made it part of their mission to coordinate social services, along with the clinical services they already provide, to their high-needs, high-cost patients (HNHC).
Their efforts begin by determining the patient cohorts within their system that would need such services. Then, a team of Health Advocate Student Interns (HASI) schedule one-on-one appointments to construct a care plan around their specific needs and obstacles. However, the path to achieving this is littered with siloes, open communication loops, and a lack of communication between the sectors of care.
For example, systems, such as Electronic Health Records (EHRs), previously LCH’s only viable system for identifying patient health information, may be able to convey the basic health status and medical history of a patient, but without an integrated referral function, the platform has limited use cases. Furthermore, the existing EHRs are void of Social Determinants of Health (SDoH) tracking features, thereby excluding a major aspect of a comprehensive health management plan.
Without a central platform on which SDoH-integrated care plans can be constructed, resources coordinated, outcomes tracked, and participating agencies can view and comment on patient profiles in real-time, the capacity for a sustainable care coordination model is out of reach.
Solution
Our team is providing support to LCH by creating a bespoke version of the path/net and path/bridge modules. Additionally, our team is working with the data provided by LCH to develop a tool capable of screening for Social Determinants of Health (SDoH) and providing an overlap analysis of agencies that are frequented by their patients.
In doing so, LCH care team members will be able to identify the individuals that fit the HNHC criteria and map resource utilization patterns. Thus, a cohort of preferred agencies are identified and focused resource mapping is achieved to optimize and streamline the referral process. By doing this, LCH’s team of HASI can use the screening tool to determine individuals that fit the HNHC profile, based on a pre-determined set of inclusion and exclusion criteria.
On a daily basis, LCH’s patient data will sync to path/bridge and path/net to ensure that information is always up to date. This is especially useful for scheduled appointments, as the screening tools and Protected Health Information (PHI) for each patient is prepped and ready upon the patient’s arrival.
Furthermore, the cloud-based interface of path/bridge along with the referral functionality of path/net will be used to combat the siloes that previously prevented a smooth and comprehensive care coordination flow. Using this system means that LCH will have a method of linking referrals, not only to other clinics and hospital systems, but also to social service agencies and Community-Based Organizations.
Integrating outcomes assessments, real-time, two-way communication features with all participating agencies, including emailing, phone-calling, and text messaging, and care plan management tools into the platform means that the HASI team will be equipped with the tools to seamlessly and efficiently provide care coordination services to their HNHC patients, while closing the loop on cross-sector communication and PHI sharing.
Critically, this model has the potential to scale across the national healthcare system and manifest a new norm of improved outcomes for patients, real-time referral management, and a reduced cost to the system.
To learn more about Legacy Community Health’s work, visit their website at https://www.legacycommunityhealth.org/
