Value-based payment models like accountable care organizations are increasing pressure on hospitals to not only address medical issues but also address the social determinants of health by connecting patients with programs that address social needs like food, housing and transportation. With this emphasis, many hospitals are enhancing their ability to take a holistic view of the patient upon discharge.
They are taking steps to ensure their diabetic patients have enough to eat, their elderly patients have caregiver support, that all patients have rides to follow-up appointments and other social factors that could jeopardize a positive outcome are properly addressed.
The following seven steps can help your organization get a program designed to address social needs of patients off the ground.
1. Establish a standard of asking the uncomfortable, but necessary, questions. A lack of caregiver support isn't always obvious. The same is true for myriad other social needs like food insecurity, transportation issues and joblessness. Hospitals and other medical organizations that are truly focused on patient-centered care have learned not to shy away from asking questions about the social determinants of health for patients, whether they have known needs or not.
Not all individuals will admit need, or admit to the full scope of the need they face, without gentle guidance. Take the time to establish an internal process and specific team roles to approach patients with sensitivity and tact. Work with your patients to identify social needs that will impact their health outcomes. Programs like the PRAPARE program, which is freely available and can be explored by hospitals looking to establish a standard, is a good place to start without re-inventing the wheel.
2. Identify key performance factors that make a difference to your organization. What is important to your team and your management? Your priorities should dictate what metrics and staff-patient interactions should be tracked as part of measuring the effectiveness of your referral process. Your team may want to understand what types of needs are most prevalent among your hospital's patients by measuring the number of searches that are made in your referral solution for programs in specific categories, like food, shelter, or job training. Your team may need to perform gap analysis in your area to determine if programs that meet patients' needs are available. It may be important to track relationships with partner organizations and measure the number of referrals that are pursued and completed, effectively closing the loop.
User adoption, program coverage, patients helped and referrals made are all common areas for performance evaluation. Identifying the priorities of your organization ahead of establishing a centralized system for making referrals will help ensure the system meets your needs and is measurable from the start.
3. Adopt a centralized system that makes it easy to find social program resources. Immediate access to resource information is necessary to quickly make referrals to appropriate services for patients. But favorite social services and community resource information is often held in notebooks on a care manager's desk or, at best, in an electronic spreadsheet on a shared drive. New solutions to establish continuity and centralize information must be easy to use and save time or there will be challenges with user adoption.
When evaluating or developing centralized systems, make sure your team can quickly search all programs available to your patients. There should be easy-to-understand categorization, and programs tagged for the populations they serve and the services they provide. An easily accessible way to make a referral to a program and follow up to ensure the patient received services is important to hospitals that want to track and measure the success of their referral system.
A user-friendly solution will also allow staff members and organizational partners, such as front desk staff at a provider's office, to help navigate patients to resources.
4. Make sure social services and community resource provider information is up to date. The credibility of your staff depends on their ability to connect people in need with the programs that can help them. Even with a centralized system for finding program resources, it is critical to ensure information on the agencies that can help your patients is continually updated and verified for accuracy.
If a patient is referred to a program that is defunct, not available to your patient due to qualification factors, or unresponsive to their needs, your patient is less likely to trust your services.
An accurate and updated database will also promote adoption and usage of the solution. It will help avoid situations where trust is lost with the patient if a referral is made with inaccurate information.
5. Empower patients to self navigate to social services and community resource agencies. Provide your patients the tools they need to help themselves through tough situations, either with your direct assistance or via accurate and updated tools that you provide them. There will be times when a patient develops a new social need when they are not engaged with a staff member. There may also be sensitive human service needs that patients are not comfortable sharing with hospital staff.
Empowering patients to self navigate solves these challenges and still allows for information to be collected on needs that can be solved with the help of a community resource.
6. Collaborate with the social services or community resource agencies to which you are referring patients. Nonprofit and government human service agencies have their own missions and goals, many of which align with the missions and goals of hospitals. Both focus on helping people in need to achieve better outcomes.
Establish relationships with the service organizations that your team has found responsive to patient needs. Jointly determine the patient criteria that will make your referrals successful with their programs and identify statistical information that can be shared between organizations to improve outcomes for all patients without violating patient confidentiality. Consider developing plans for community programs that can benefit both organizations; for example, staff from the hospital can provide nutrition classes at a family shelter.
By identifying common goals and forming a partnership, both parties can work together to improve the health of the community.
7. Regularly review performance metrics and iteratively improve your internal processes. Your centralized human service referral system can provide your team with a wealth of data to track your key performance indicators. This may include specific areas of human service needs for your patient population such as which agencies are being referred to most often and how many times they were able to provide help. It may also extend to employee performance data such as which employees are regularly making referrals. Tying this information to patient health data can show which community resources or social services activities are having the greatest impact, guiding best practices for your organization, and allowing your team to make incremental changes to improve processes.
Chris Dunkin spends his days working to help organizations connect people in need with the programs that can help them at AuntBertha.com. His 10 years of experience with nonprofits and hospitals providing social services, as well as his experience helping major hospital and insurance systems implement social referral and tracking programs, puts him at the forefront of the teams setting the standards for the industry.
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