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Jessica Kent

At the Alliance for Better Health, an interoperable digital platform is connecting providers and community leaders to effectively address individuals’ social determinants of health.

In care delivery today, it’s well understood that a patient’s social determinants of health have a profound impact on both physical well-being and healthcare spending – sometimes even more so than clinical factors.

Evidence has shown that industrialized nations that dedicate more resources to social services than healthcare tend to have better health outcomes.

A 2019 report from the National Academies of Sciences, Engineering, and Medicine revealed that for every $1 the US spends on healthcare services, it spends about 90 cents on social services. In comparison, other industrialized countries spend $2 on social services for every $1 they spend on healthcare. 

Although the importance of addressing individuals’ social needs is widely known, many providers still struggle to identify and document the non-medical factors affecting patients’ health. And even if they can, clinicians then have to clear the next difficult hurdle: referring patients to the right services that will meet their needs.

“When I was a family doctor and a patient would tell me about a need that our organization didn't address – such as housing instability, food insecurity, or transportation challenges – often I would look something up quickly on the internet and then scribble the number of some kind of service on a yellow sticky note,” Jacob Reider, MD, CEO of the Alliance for Better Health, told HealthITAnalytics.

While better than nothing, this method was not exactly effective, Reider said. There was no way for providers to tell whether a person actually received the services that were recommended to them. Clinicians also had no way of knowing if the referred organization could adequately meet a patient’s needs.

To help clinicians communicate more easily with social service entities, Reider and his team partnered with digital referral platform Unite Us, implementing their platform to develop Healthy Together, a closed-loop network that connects physicians, organizations, and community members in one platform. The tool allows Alliance to quickly identify and address social determinants of health, eliminating silos between each party.

“Healthy Together solves a problem that many communities have – and are our community was certainly one of those many,” said Reider.

“At Alliance, we recognized the gap between services needed and services provided. A referral is open forever because we were never tracking whether or how the loop was closed. Our platform makes sure that the loop does get closed.”

The first step in developing the platform was to find social organizations that would pledge to respond to requests for services, Reider noted.

“Healthy Together is a commitment from all participating organizations to send referrals and to receive referrals. If a referral is received and the services provided, the organization needs to document that in the system so that we know the referral was closed,” he stated.  

“And if the referral wasn't closed for any reason, we want them to say the service wasn't provided. Either that individual didn't appear, or they were hard to reach, or perhaps that's not the right organization. We did this so we could make sure that people receive the services they need, when they need them.”

The platform also ensures that the people who administer these services can easily access and update relevant information.

“There are clinicians who access it, but more often it’s care coordinators or social workers who work in either hospitals or medical practices,” Reider said.

“Community organizations access the platform as well, including food pantries, homeless shelters, job assistance providers, and substance use disorder treatment facilities. They all have logins and they can both send and receive referrals through the system.”

With all of these different players accessing and updating the tool, interoperability is a critical part in the successful design and deployment of these platforms, Reider said.

“In communities where we need to communicate both the need and the services, you need a common infrastructure and interoperable systems to make all of that work,” he said.

Industry-wide standards are also necessary to help organizations address patients’ social determinants – a refrain that has been echoed by leaders in all sectors of healthcare.

“Step two is implementing standards so that the systems can talk to each other. Without standards, it’s really hard to make that happen,” Reider explained.

“If you're looking into a solution like this, you need to ask the question, are we using industry standards? How interoperable is the system? And that's very different from how integrated the system is. Integrations don't use industry standards, whereas interoperable components do and are much easier to maintain.”

In addition to establishing a common infrastructure and standards, leaders will need to determine how they want to measure the value of this kind of platform.

“The first step was defining success, and one definition of success is that the loop is closed and the service was provided. When we started, we were seeing service provision rates under 50 percent. That means that if I refer a hundred people for services, less than 50 of them got those services,” Reider said.

“We are now measuring that rate on a daily, weekly, and monthly basis. We're now in the upper seventies of percentages, which is significant when compared to other communities.”

Alliance decided to use another measure of success as well: the health of the community.

“We’ve started measuring how frequently individuals have to go to the emergency department for things that generally would not warrant an ER visit. An easy example is asthma exacerbation in a child. Kids shouldn't ever have to go to the hospital for asthma. If they have to go to the hospital for asthma, that means that their asthma is not controlled,” said Reider.  

“If their asthma isn't controlled, then there's a problem. And likely the problem stems from their environment. Maybe they couldn’t make it to the pharmacy and get their medications because there was a snow storm and they had transportation challenges. There are social issues that have medical consequences. When we measure the medical consequences, we can get a broader perspective on whether we are succeeding.”

Through the use of platforms like Healthy Together, healthcare leaders can partner with community organizations to better understand and meet patients’ social needs.

“We developed this platform because we recognized that none of us meets all the needs of an individual. Instead, it takes a whole community to meet all the needs of a patient, and we need to share that responsibility. Healthy Together prompts folks to think more broadly about how we serve people, and then makes it easy for them to act on those expectations,” Reider concluded.