Problem
Clinic systems like Partners in Primary Care (PIPC) provide essential services around primary care needs for patients and are starting to look at Social Determinants of Health in a new way, by bringing the service of connectivity and referrals to Community Based Organizations (CBOs) within the clinic setting.
PIPC does this by having care coaches at the clinics, who fulfill the role of a care coordinator. This role involves engaging with a patient in a one-on-one setting to establish an individualized care plan that includes coordinating resources and services outside of the PIPC clinic system, based on the needs and goals of the patient. This can be accomplished by a variety of board-certified healthcare professionals, from doctors to physician’s assistants to resident nurses.
In doing this, care coaches are fostering an environment that proactively involves the patient in the treatment process, thus motivating them to take control over their own “health journey,” increasing retention rates and improving outcomes.
However, while this is a holistic and innovative approach to health management, the infrastructure to accomplish these goals is lacking. There is no coordination between the agencies providing care to a given individual. The communication barrier between cross-sector agencies, on the patient and community level, and the lack of a central patient-tracking platform contribute to the siloed nature of care in the current healthcare system.
The challenges are particularly acute for clinic systems, such as PIPC, that face bottlenecks in the referral process. For a high-traffic agency that provides and relegates care, efficiency and timeliness are key components that are missing to improve patient outcomes. This means that while someone may eventually receive the resource they need, the process is inefficient, and in periods of scarcity, the resource may not be available at the time of need.
For care coaches, the inability to track the utilization patterns and health outcomes of receiving individuals and agencies participating in this process further complicates the ability to construct, analyze, and follow through with a care plan. In order to overcome these challenges in the system, a comprehensive solution must be in place that integrates cross-sector data sharing, care planning, and care coordination functionalities on a unified platform, centered around an individual’s needs.
Solution
Our team and Partners in Primary Care (PIPC), a subsidiary of Humana Inc. dedicated to providing patient-centered care to those looking to overcome an ailment or simply maintain their health, have launched an initiative to connect community-based resources to PIPC’s members that are in need of social services, such as food insecurity, economic instability, housing, and more.
Our path/bridge and path/net platforms will provide PIPC’s care teams a way to coordinate social and medical services through real-time referral integration, manage individual care plans, share HIPPA protected patient health information (PHI), and track members’ abilities to address Social Determinants of Health (SDoH) needs, while providing an excellent member experience and increasing retention rates among PIPC’s Houston-based members.
path/discovery will serve as a data reservoir, from which our team of data analysts can determine geographic resource mapping and utilization patterns around the city. These functions are supplemented by our account managers’ training on the Values-Based Model approach to care to allow PIPC’s care team to efficiently construct an individualized care plan for each member.
