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Lynda Bascelli, MD, chief medical officer of Project H.O.P.E. provides primary care services for the homeless population in one of the nation’s poorest cities, Camden, N.J.

Her organization is working with the Camden Coalition Health Information Exchange (HIE) to share patient data with social service agencies and the county jail.

“Getting social service agencies to become more involved is very important, especially with an underserved population like ours,” Bascelli says. “We are trying to get their diabetes or hypertension under control, which is virtually an impossible task when someone is not housed. It is a ridiculous thing to be talking to them about when they are scrambling for basic shelter.”

Health systems are becoming increasingly aware that social determinants of health (SDoH) can have as much impact on patients’ health as the type of care they receive from provider organizations. Therefore, population health improvement initiatives are relying on closer collaborations with the healthcare and human services sectors.

The focus on SDoH also requires that data flows across sectors that aren’t accustomed to collaborating. Most physicians are familiar with HIE organizations, which share lab results and orders with hospitals and other providers.

But several regions of the country are independently expanding their efforts to create community information exchanges (CIE). These CIEs, some created with support from the Robert Wood Johnson Foundation, link data and facilitate online referrals among medical providers and social service agencies involved in housing, food services, transportation, and corrections.

For example, physicians using the Camden Coalition HIE can be notified when their patients receive care in the jail’s medical system. Most of these efforts are just getting underway in 2019, starting with federally qualified health centers (FQHCs) and Medicaid accountable care organizations (ACOs). After working through governance and patient consent issues, the founding organizations are now turning to how physician offices will use the CIEs and what types of social determinant data physicans want to see.

Initially, the Camden Coalition started in 2010 to focus on helping social service agencies get access to some medical data. Once they had medical data flowing to social services, the next logical step was for clinicians to be more aware of social challenges their patients are facing.

“For the patients our care teams serve, their medical complexities are often related to their social needs,” says Christine McBride, program manager of Camden Coalition HIE. “We are documenting those connections to social service agencies in our HIE to make sure it is not just one social worker who knows the patient is experiencing homelessness, but also the nurse, the physician, and the community health worker.”

Treating the whole person

Perhaps the most ambitious efforts to create a more holistic view of patients are taking place in California. The state’s Medicaid program, Medi-Cal, is working with 25 counties to pilot an effort called Whole Person Care to coordinate health, behavioral health, and social services.

The counties are starting to share data and coordinate care for vulnerable Medi-Cal beneficiaries who have been identified as frequent users of multiple systems with persistently poor health outcomes. All counties are deploying relatively new technology platforms, usually from startup companies focused on this market, to allow previously siloed organizations to share data, create shared care plans, and evaluate the progress for both an individual and the population.

In Marin County, the Whole Person Care program is using a technology platform to provide physical and mental health data to social service agencies and deliver SDoH data back to a clinic where nurses and care coordinators can review the information.

The program has intentionally not yet incorporated physicians, says Ken Shapiro, director of the county program. “We know how valuable physicians’ time is,” he explains. “We have a phased roll out. Case managers and social workers are already using the platform. We want to get critical mass of care coordination nurses to use the system, work out the bugs, and work up the chain to the physicians.”

Care teams that include healthcare providers and social workers can use the platform to message each other, says Shapiro, who describes it as similar to having a discussion on Slack, the cloud-based collaborative work platform. Participants can begin a conversation about a patient, and the rest of the care team can see it. If a particular provider is mentioned, she will get notifications sent directly to her inbox.

“It has been a game changer for social service providers and community clinics to have this awareness and connection to other providers across the continuum,” he says.

One example of the platform’s value is for patients who are homeless and have mental health disorders. Often, they are unable to send in the necessary paperwork to prevent their benefits from expiring.

“We have someone monitoring people on the platform and updating their case managers on where they are with benefit expiration and renewal,” Shapiro says. “That information is now shared securely for all clients who are managed through Whole Person Care. We can keep them from popping in and out of social services, which is a huge determinant of health.”

It’s important to keep patients enrolled, as people who lose housing or food benefits tend to have much poorer health outcomes. Early intervention can improve their health, which ultimately saves the healthcare system and taxpayers’ money.

San Diego builds a care network

In southern California, local nonprofit 2-1-1 San Diego has built a CIE with 53 network partners across all sectors. 2-1-1 San Diego is just starting to use the CIE to formalize referral pathways from smaller physician practices with the goal of also adding independent practices to the network. The CIE includes a social risk assessment tool and sends alerts for emergency services or if the client is in jail. It also facilitates connections across multiple agencies and providers.

2-1-1 San Diego started in 2010 and has built relationships with area healthcare providers that have physician organizations, including Rady’s Children Hospital and Sharp HealthCare, an integrated health system. “Now they are ready to take it to the next step and send data to the CIE,” says Camey Christenson, senior vice president at 2-1-1 San Diego.

She says the CIE has created a longitudinal client database that gives clinicians a snapshot view of their clients’ records. So, when a physician is trying to see if her patient is homeless or food insecure, she can look in the client record and see an overall color-coded client risk assessment rating, which is determined by the different agencies that conduct domain-specific risk assessments. She can then click deeper and see the assessments, the EMS transport history, or jail booking history.

“The technology and build-out were the easy parts. It is re-engineering the business processes that is difficult,” Christenson says. “The social workers and health plan care managers already understand the value. We are trying to move even further into the clinical setting.”

Inputting SDoH into the EHR

An added twist on the CIE concept is to have safety net clinics gather SDoH information from patients and input the data into their own EHRs. Oregon-based nonprofit OCHIN provides EHR support services for 450 community health clinics with more than 10,000 clinicians across the nation. It has built EHR tools and worked with member clinics to develop workflows for gathering SDoH information.

“There is an increasing realization that these issues determine the patient’s capacity to get better and have good health, and the way to get that information is to ask,” says Scott Fields, MD, OCHIN’s chief medical officer.

The first thing OCHIN did was build and pilot a tool to gather the information. “We have learned it is not always easy to ask the questions, nor is it always easy to follow up on what we learned,” Fields says. The second step, he says, is for clinicians to learn about the area’s resources and develop a process for patient hand offs to close the loop. This allows clinics to see whether patients went to a food pantry and, if so, what sort of help they received.

Fields says that means asking the right questions. Then, it’s documenting the answers, developing a methodology to respond to any issues, and creating a communication network among partner organizations.

There is no question that clinicians want to know about and address social determinants since they are so critical to patients’ well-being, but Fields says there are still questions about cliniciains’ capacity to do this in addition to what they are already doing.

It’s not easy, but Fields says healthcare providers must find a way to make it work. New payment reform initiatives will incentivize providers to create more community information exchanges.

The good news is that it’s possible-and it’s working. Back in New Jersey, the Camden Coalition Accountable Care Organization (ACO) brings together Camden-area hospitals, primary care and specialty providers, behavioral health providers, community organizations, and residents to coordinate care for local Medicaid beneficiaries.

“I see a lot of excitement around the idea of care planning with social service agencies,” McBride says.

One of the coalition’s goals is to make sure patients are seen by a primary care physician within seven days of hospital discharge. The coalition is already seeing positive results.

Camden Coalition HIE studied 1,531 hospital discharges from Jan. 1, 2014, to April 30, 2016. The coalition found post-discharge primary care appointments within 7 days increased from 19.3 to 39.2 percent, meaning appointments more than doubled as a result of the program. It also found there were fewer 30- and 90-day readmissions in comparison to patients who received no or less timely primary care follow-up.

“Knowing what to do after that primary care visit is where I have heard a lot of providers saying they wish they had better communications among all the ways a patient is served,” McBride says.

David Raths is a Philadelphia-based freelance writer focused on healthcare and technology.