07-26-2021 Responding: Using Data for Social Interventions

Tiger Team - Responding SI Presentation.pdf

Discussion 

• How does your organization share information with community partners about your patients’ social needs or interventions (e.g. data system, process)?
  • Very different from center to center- it is not a uniform approach.
  • Unite Us
  • Azara 
    • Our Health Centers have implemented PRAPARE and using it to gather data but each health center has an informal process on how they are utilizing the data. 
  • There is not the same support in EHRs for community services as compared to referring a pt. to a medical specialist- there is a process for that. Because of that it is difficult to conduct a follow up for social needs. It is documented in the chart note but very informal. 
  • Progress is hard to get the EHR systems to share data with each other and with the community partners.  When trying to conduct closing the loop on referrals bi-directional communication is crucial and it is currently a struggle. 
    • Gravity project- task on hand is it figure out the technical aspects of sharing data from CBOs into the healthcare provider realm  
• How is sharing data with your community partners to close referral loops helpful?
  • The patient is responsible for taking the step to access the resource, so us or the partner updating the patient's f/u status is helpful.
    • Good to consider when your thinking about close loop status/definition. You can provide the resource but if the pt. does not take action is it fair to call it closed? 
  • Health Centers are VERY interested in being able to share the data with community partners- but it is a challenge. Being able to share data would allow 
    • The ability to evaluate the resources that are available 
    • Knowing if the resources is helpful- for example being aware of the  barriers or limitations or the resource. Are the resources truly accessible?
  • Azara- starting to porotype a social interventions enabling services template that integrates with SDOH data that might be collected by HCs. Could potentially use this tool to map out referrals/ close loop referrals in the future.  
• Is there anything missing in the presented workflows that needs to be considered?
  • Understand that there is no one size fits all with workflows and closing the loop 
  • Noted that the documentation is a hefty item to complete and can become burdensome- need to make it as simple as easy as possible. Taking advantage of the technology 
  • Presented as different workflows depending on the role of the person who is leading the work 
• What is the best way to share social needs & interventions (e.g. closed loop referral) data with social care providers including community-based organizations in order to address patient social needs?
  • Bidirectional communication (internally and externally)
  • Review the data 
• What data platforms are best to share social needs/interventions data between CBOs and CHCs (e.g. for patient closed loop referral status)?
• What should be considered as we develop a plan for pilot implementation?