Using Technology to Address Disparities, Integrate the Social and Medical Needs of Patients

Events of the past weeks and months are laying bare the endemic health disparities in the United States. Experts believe technology has a significant role to play in correcting these gaps and providing improved care for all. 

As COVID-19 continues to spread amidst economic and social unrest, the disproportionate number of minorities hospitalized with and dying from COVID-19 starkly reveals persistent inequities in health and health outcomes and the ongoing challenge of creating an equitable healthcare system supported by needed social structures.

Although individual risk factors, such as underlying comorbid diseases like diabetes and obesity, are often cited as the reason for the increased burden of COVID-19 in minority populations, other social factors are likely in play or contribute. Recent population-based analyses are showing the important affect of social determinants of health on populations and communities that place them at increased risk of contracting and dying from COVID-19. Recent studies highlight that counties with a higher proportion of Black residents have higher rates of COVID-19 diagnoses and deaths.

A study from the Massachusetts Institute of Technology (MIT) found that the mortality rate from COVID-19 was 10 times higher in counties with a Black population above 85% compared to a nationwide average county level death rate of 12 per 100,000 people. This study also showed that after controlling for factors such as income disparities, not having health insurance, or comorbid conditions such as diabetes and obesity, the significantly higher mortality rate among Blacks remained. Factors suggested as accounting for this include lower quality of health insurance with less access to a primary care physician as well as lower quality of care when accessing the healthcare.

Teasing out a causal relationship is needed, but this data adds to the growing evidence on how the social factors of where people live affect their health. Addressing these social determinants is taking on an urgency like all else during this pandemic to both relieve the effects of COVID-19 and to better address the ongoing health disparities among these high-risk populations.

“The devastating impact of the pandemic will hopefully catalyze the pace of social and medical care integration, and the activism in response to the death of George Floyd has further propelled advocacy regarding where we invest our resources,” said Lynn Warner, PhD, Dean of the University at Albany’s School of Social Welfare, Albany, NY. “Altogether, this is the time for actual, tangible interventions focused on social needs.”

Such interventions, she noted, will require investment in technology similar to investments being made for things like telehealth and electronic health records. “It is important to foster partnerships with the tech industry, intentionally brokered so that social care and health care platforms can be harnessed for tracking the array of patients’ needs and monitoring outcomes.”

To date, a number of models trying to address the social needs of patients have relied on social workers or community workers as part of a health care team to identity patients with social needs and link them to community resources. Dr Warner highlighted two models.

One is the Ambulatory Integration of the Medical Social (AIMS) model in which social workers are embedded into primary and specialty care teams to assess the needs of patients with complex medical and social needs and to coordinate their care. Data shows that patients treated within this model have fewer hospital admissions, emergency room visits, and their health risks and depression scores are lower compared to other patients.

Hotspotting is another model. Created by the Camden Coalition of Healthcare Providers, hotspotting strategically uses data to reallocate resources (social needs assessment and case management) to a small subset of high-needs, high-cost patients to lower readmission rates. The model relies on a team of social workers, community health workers, and nurses to engage with patients after hospital discharge to coordinate their outpatient care and connect them with social services. The model has generated widespread interest, although the impact of this model on reducing hospital readmission was recently challenged by randomized data published in the New England Journal of Medicine showing no significant difference of the program on outcomes.

In more recent years, health care organizations are testing technological platforms to streamline the work of identifying high needs patients and connecting them to community resources. A number of technology startups are entering this space, including platforms called NowPow, UniteUs, and CityBlock Health.

Below are two examples of how one of these platforms, NowPow, is being implemented to address the social and medical needs of patients with complex needs and high costs.

Referral Platform in Practice: Examples of Implementation

In October 2019, Northwell Health launched a pilot project using NowPow to connect their Health Home’s Health and Recovery Plan (HARP) patient population to community-based providers. This patient population is highly complex and high cost with multiple chronic conditions—including potentially HIV positive and/or with mental and/or substance misuse problems—who face a number of social challenges such as homelessness or home and/or food insecurity.

The pilot is using PoweRx, one package within NowPow’s software platform, that facilitates and streamlines connecting patients to community-based organizations (CBOs). Explaining how it works, Stephanie Kubow, MPH, Assistant Vice President of Community Health, Northwell Health, NY said that a member first undergoes the state mandated Health Risk Assessment to identify the member’s social needs. Once identified and then approval by the State and member, the case manager then uses the NowPow software to begin the referral process to the appropriate community-based organizations (CBOs).

For the pilot, Kubow’s group identified 8 CBOs that focus on addressing the specific needs of HARP members, which are referred to as home and community-based social and mental health services. If a patient has a need outside the scope of these services, NowPow has custom algorithms that permit accessing a list of CBOs outside the network. “From there the referral list, called a “HealtheRx” can be texted, emailed, or printed in over 100+ languages and directly given to the member,” said Ms Kubow.

Although no outcomes data are available, Ms Kubow emphasized that NowPow has helped to streamline the process. “The seamless nature of the platform’s functionality is crucial for people with very complex needs,” she said, adding that prior to the use of the platform connecting patients to services was labor intensive without a good way to track whether services were being utilized.

“Given that we now have the capability of doing everything in one platform makes it more efficient, and that enhances the ability of the team to see what is happening in terms of outcomes, and then help to address any issues…with the ultimate goal of improving these patients’ health outcomes,” said Ms Kubow.

Allina Health is also using NowPow for identifying social needs in its Medicare and Medicaid beneficiaries and connecting them to community services. Launched for use in 2017 as part of a 5-year cooperative agreement with the Centers for Medicare & Medicaid Services (CMS) through the Accountable Health Community Model, NowPow is being used to screen patients at 79 screening sites across the Allina Healthcare System including all outpatient clinics (primary care, Ob/Gyn, mental health) as well as in 3 hospital emergency departments (ED).

Dan Behrens, MHA, Program Manager for Accountable Health Care Community Model, said that the NowPow build for Allina allows clinicians to separate the patient population into low-risk and high-risk (ie, >2 ED visits within the last 12 months and at least one social need) groups. NowPow generates a referral summary for all patients identifying a need in the screening, but the intervention differs based on risk. Low risk patients are encouraged to find and follow up on the services they need using the tailored referral summary provided, while high risk patients are given additional support to link them to resources.

Behrens highlighted the benefit of NowPow’s interface with the electronic medical record to connect people via email or after-visit summary and to track referrals between providers and community organizations. “The more clear communication is between organizations, the more patients benefit from the model and receive the support they need,” he said.  

Ellie Zuehlke, MPH, Director of Community Benefit and Engagement at Allina Health, said that to date over 350,000 people have been offered a screening through the Accountable Health Communities model of which 50% have completed a screening. Of this 50%, over 25% identified at least one need. Although no outcomes on the efficacy of the Accountable Health Communities model are available yet, screening data show a strong correlation between identified needs, higher ED utilization, and worse health outcomes, she said.

Both Ms Zuehlke and Mr Behrens emphasized that simply using a software program to address these social determinants of health is not enough, but that a cultural shift is needed within organizations and among providers to fully realize the need to address the whole person in healthcare.

Mr Behrens pointed out that talking to patients about food or home scarcity or other social needs is not natural to many medically trained providers and support staff. The biggest barrier to addressing these needs, he thinks, is the discomfort of providers to ask questions for which they don’t readily have an answer—like food scarcity or homelessness. “I think this has prohibited providers to this point,” he said. “When you don’t have the tools to support this in a streamlined way, it is hard to get buy in and support from providers.”

But Mr Behrens is hopeful that providing the right tools, such as NowPow, will change that.

Ms Zuehlke agreed. “Culturally there is that expectation or mental shift that addressing social determinants of health is part of the way we provide health care and it is not just the social worker who does this,” she said. “That cultural shift combined with those practical tools is incredibly important.”