Tending to social determinants of health with software

Healthcare providers are abuzz about the importance of social determinants of health—things like access to housing and fresh food. They're increasingly insistent on connecting patients to community organizations that can assist in these realms.

But for all their buzz and insistence, they're having a hard time actually making the connections. And even when they do, they might not even know it, since it's tough to track patients' activities outside the traditional healthcare system.

Software developers are hoping their tools will be just what providers and community organizations need to coordinate care when it comes to the social determinants of health.

“This is going to become more and more common as people realize the need to move off the paper binders that sit on desks to something more real time,” said Anita Cattrell, chief innovation officer at Evolent Health, a managed-services company that helps systems transition to value-based care.

At Rush University Medical Center in Chicago, this takes shape in NowPow, software for connecting patients to community resources. In 2017, the software cost large health systems between $50,000 and $150,000 in annual subscription fees. The company now says pricing depends on product selection and the number of users.

Rush providers are using NowPow, integrated with its Epic electronic health record system, to direct patients toward resources for addressing social determinants. When a provider enters a patient's social information into the EHR, it flows to NowPow automatically using the FHIR standard. The software then figures out how patients might benefit from working with community organizations and produces a prescription of sorts with recommendations.

The software is a big step forward from how things used to be at Rush, when social workers had individual files for community partners. “Having no access to the patient after they're gone was just not a good experience overall,” said Jeremy Marut, lead solution engineer at Rush.

The key will be what those in the social determinants of health business call “closing the loop”: Feeding information back into NowPow after patients have visited community resources, so information flows both ways. “If you don't have a closed loop referral, then you don't have the data, and you don't know they showed up,” Marut said.

Because many of the organizations Rush works with don't have NowPow installed, closed loops aren't common, at least not yet. That can pose a challenge when it comes to measuring success and keeping track of patients.

It can be difficult for community organizations to implement software, Cattrell said. For these organizations, “it could become really burdensome if one person is using (software made by) Healthify and another is using NowPow, so there's the burden on them to use whatever software the provider is using.” It is, in other words, a problem of interoperability.

Right now, two community organizations that work with Rush use NowPow and can share information.

For those organizations, the closed loop has been a boon. CommunityHealth, a medical home for people without insurance, used to track patients with Microsoft Excel. Now it uses NowPow, said Emily Hendel, director of clinical services for CommunityHealth. The organization is also using the software as Rush does, to connect patients with information and resources. “If we'd been doing the screening without a platform to get the information out to people, I don't know how we would have done it,” Hendel said.

Other vendors, including Healthify, offer similar software to help hospitals and community organizations track patients as they address social determinants of health.

Aunt Bertha, another solution, is particularly popular because it's simple to use, Cattrell said.

Rush is using its data collected to identify “health deserts” in Chicago and to figure out how Rush might get pharmacies and urgent-care centers in those areas. The health system could then track how those additional resources translate to preventive care and reduced readmissions, among other metrics.