Solving social determinants of health (SDoH) requires going beyond the closed-loop referral. Community and health partners must continually collaborate to solve the needs of vulnerable people.
Picture this: Mary, a pregnant mother on Medicaid, lacks reliable transportation, causing her to miss prenatal visits.
Conventional wisdom says that by sending Mary a referral for a ride-sharing service you’ve solved her social needs. . . right?
Wrong.
As more organizations look to adopt technology and services focused on addressing SDoH, there’s a fundamental misconception that continues to put real outcomes at risk.
The reality is that most vulnerable people and their families don’t experience SDoH one at a time. These are complex and interrelated issues; providing a simple “closed-loop referral” doesn’t tell us who Mary was before her appointment, what happened during her appointment and after she went home, or about any other social factors influencing her maternal health outcomes.
In order to sustainably improve health, quality, and financial outcomes, organizations need visibility into the full timeline of life challenges faced by people like Mary.
If she needs a ride, does she also lack financial resources to fill her prescriptions? Is Mary without access to healthy food, which raises her risk for gestational diabetes? Is she participating in unhealthy behaviors that will affect other outcomes?
Preventing ED and NICU time, and improving maternal outcomes for Mary takes more than a resource directory or closed-loop referral platform; it takes true collaboration between a thriving network of community and health partners.
Building safe-sharing networks that solve SDoH in your community
Bringing together payers, providers, agencies, and community organizations on one shared network allows these virtual teams to collaboratively address the full spectrum of Mary’s complex social needs.
Only when covered and non-covered entities have the ability to safely communicate, share referrals, and manage a social care plan can this network provide a level of wrap-around support necessary to solve the multiple SDoH of at-risk and vulnerable populations.
As Mary moves throughout the community, intersecting with various health providers and social services organizations over time, this network can document, track, and manage her social needs and referrals, creating a comprehensive social record.
The result is that network participants can better understand Mary’s social circumstances, connect her with the most appropriate community resources to solve her needs, and develop upstream strategies to assist her before a clinical event occurs.
Creating alliances of community and health partners requires a novel combination of privacy protections, technology, and proper sharing agreements.
Learn how TAVHealth can help you build outcomes-based collaborative networks in your community by joining a complimentary webinar hosted by Jamo Rubin, MD, Founder and CEO of TAVHealth.
Building Collaborative Networks that Solve SDoH & Drive Outcomes
Tuesday, October 16, 1:00–2:00 p.m. CST
To learn more about TAVHealth, read case studies, and view real-world outcomes, visit www.tavhealth.com.