Written by To effectively manage patients with complex conditions, thoughtful integration of physical, and mental health services with social care is critical. Social determinants of health such as housing, transportation, and food insecurity are directly correlated to health outcomes. However, social services have been operating in a silo and disconnected from the broader health system. These navigation and coordination problems are leading to a higher incidence of emergency department visits, hospitalizations, and increased costs of care, and often blunt the impact of social services.
Government organizations are recognizing the opportunity to better address health-related social needs, and have started offering new programs such as enhanced care management for high-cost, high-need members. These programs are created to address the clinical and non-clinical needs of the most vulnerable enrollees through intensive coordination of health and social services. By providing necessary services that address unmet social needs, health systems and healthcare payers can prevent or greatly reduce admissions to unnecessary institutionalized medicalized care. However, it has been difficult to implement. The primary care providers lack the resources to address the social barriers and community-based organizations (CBOs) lack the technical infrastructure to provision, manage and report social services.
To successfully implement a comprehensive care management program, that is integrated across both health and social domains and designed to produce high-quality outcomes, you need a data-driven technology-based platform. This integrated digital care management platform can enable your care management teams to identify the social care gaps, work with community managers and connect patients with resources that promote healthy living, wellness, and independence. Health systems and healthcare payers can benefit by enabling their partners across sectors to send and receive secure electronic referrals and report on tangible outcomes across a full range of services in a centralized, cohesive, and collaborative system.
We all know that care happens in the community but the path for individuals to get that care is fragmented and inefficient. Sprite Health’s digital care management system provides the following six capabilities you need to successfully implement a program that connects health and social care, breaks down barriers, and works across sectors to drive systemic, meaningful change to meet your patients’ holistic needs.
1. Social risk identification
Care management and coordination resources are expensive and should be managed effectively. With our descriptive and predictive SDoH analytics, you can target patients with unmet social needs more effectively. Descriptive analytic approaches look at past data and predictive models, on the other hand, forecast future trends such as what paths members are likely to take. Understanding social care gaps will help you develop geo-targeted and intervention-focused care programs that can address these gaps.
2. Enrolling patients in programs
Careful planning during this step of the process will ensure higher and faster enrollments. Our technology and analytics can help you understand the right channels for each population cohort. Not everyone responds to phone calls. You can create content in multiple languages and deliver them using multiple channels (phones, text, emails, print) – which can significantly improve your enrollment results.
3. Care planning
High-risk, high-cost patients often have multiple, chronic, and more complex conditions. To lower the chances of patient non-adherence and duplicative services, our system helps care managers create an integrated care plan that addresses both the clinical and non-clinical needs of the patient. The care plan can be created using multiple assessments including condition-specific assessments as well as SDoH assessments. Having one care plan enables interdisciplinary care where all stakeholders can see each other’s notes, and work collaboratively towards the common goals for the patient.
4. Coordinating social care
The integrated and shared care plan includes specific interventions that address both social and clinical needs. Coordination starts with identifying the right community partner that can not only address the specific need but also keep the care coordination team updated on the progress. Our digital care management solution provides social care coordination that helps your care teams and network providers to close the loop on referrals, coordinate transition, refer clients to one another, and track outcomes.
5. Integrating data and systems
To get a complete picture of the patient’s health progression across the continuum of care, it is important to integrate data from different sources, such as EMRs, claims data, and CBOs. By integrating clinical and social information in real-time longitudinal records, you can track interactions and encounters at every stage of your patients’ care journeys across the continuum of care and get better insights into the treatment pathways, and health outcomes.
6. Analytics and reports
Peter Drucker famously said, “If you can’t measure it, you can’t manage it”. Our digital care management solution can provide you the comprehensive reporting capabilities to track SDoH and service trends across community providers, making it easy to measure the impact of their programs. In addition, you can also see how each social program is impacting ER use, preventable hospital admissions, and excess hospital stays, as well as the use of prescription drugs and high-cost imaging.
To address the needs of underserved populations and move towards a whole-person care approach, supporting non-medical needs such as transportation, housing, and nutrition is as important as medical needs. Connect with us to learn how our digital care management solution can help you coordinate care through a network of community-based partners to provide easier access to vital community services and programs. It streamlines referral management by enabling integration with referral partners across your partner networks for seamless member intake and coordination. The partners can view and receive referrals in a single location, as well as find missing clinical information from across the member’s care journey. The coordination analytics and reporting provide insights into the health and social services programs to ensure that your members are receiving the community services they need and if these services are helping in reducing emergency room and hospital visits.