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Connecting the Whole Person to Whole Care
August 21, 2017

Connecting the Whole Person to Whole Care

As healthcare providers work to deliver the care their patients need, many struggle with how to treat the whole person-their medical, behavioral, and social needs-and the best way to efficiently track their outcomes.
First Generation “Referral and Community Navigation” Technologies
Over the past 3 years, several new and reinvented healthcare tech providers have come to market to capitalize on this opportunity and provide the systems healthcare providers need.  Most position themselves as healthcare technologies designed to address social determinants of health by linking clinical and social service providers into a health continuum. 
 
But these solutions are fundamentally flawed. Instead of creating platforms that are designed to make the patient journey and data-access the focal point of their solution, they are merely digitizing “yellow pages” of service providers into curated e-directories and augmenting them with bi-directional referral tools aimed at escorting patients out of their clinical environment.  While this approach is an improvement over land locking the patient inside the clinical realm, savvy healthcare professionals realize that this approach is inadequate and overly transactional, prioritizing the referral over the patient, the health journey, and care outcomes.
 
Sadly, health continuums miss out on the opportunity to take a 360-degree view of the whole person and effectively cater to their multiple needs: social, clinical and behavioral. Instead, they are narrowly concerned with the following:
  • Was the referral made?
  • Was the referral accepted and closed?
  • Did the appointment occur?
 
Unfortunately, whether a referral is made or accepted or an appointment confirmed does not shed any light on the whole person’s needs nor does it provide visibility into their health journey, their broader social determinants of health, and patient care outcomes. Furthermore, this approach cannot track structured patient care outcome data, across multiple social service providers and patients, at scale.
 
Imagine a patient with multiple social and behavioral needs who has been referred to multiple service providers. Let’s assume one referral was for mental health, the second for opioid addiction, and the third for housing. Now, let’s assume we wanted to report on each service outcome, by provider. If we are operating from an electronic directory with a bi-directional referral tool—where the outcomes are captured mostly in free text—we would need to manually extrapolate data from each referral (was it closed?) and then make sense of the free text case notes to determine what outcome had occurred and whether it was resolved. Then, we would have to combine our notes from each service outcome. The sum-total of this laborious effort would yield an overall picture of the patient journey, assuming the case notes left no room for misinterpretation.
 
But what if you needed to report on hundreds or thousands of patients across one or multiple communities, quickly? Would this approach scale? The answer is absolutely not! 
 
As hospital systems evolve into true value-based care organizations focused on treating the whole person— body, mind and soul—it is critical that their platforms be designed to track structured outcomes, in real-time and readily generate care outcome reports by all social services types, regardless of how many patients, providers or communities are served. 
 


 
Copyright AJMC 2006-2017 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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