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Spotlight on SDOH Data: Closed-Loop Referrals for Health-Related Social Needs

Akshita Singh

Our collective understanding of the social determinants of health (SDOH) continues to make headway. We now recognize SDOH as vitally important components of health and well-being. This way of thinking is increasingly incorporated into care coordination strategies, because SDOH are often the barriers that interfere with our ability to achieve our best level of health. Healthcare organizations are now seeking ways to "close the loop" with community-based organizations that are best positioned to address these social needs.

While there is still a sense that healthcare considers SDOH-informed strategies to be something of a burden, the reality is that community-based organizations address that burden. This is why it is important for care coordination platforms like ACT.md to mesh both sets of stakeholders together in a way that all health and social needs can be simultaneously addressed. Having certain features in a care coordination platform makes all the difference in ensuring the SDOH needs of a patient are being met as well as their physical and social needs. Such features can be found in the ACT.md CareHub™, for example:

  • Ensuring that SDOH needs are addressed before a patient steps out of the office, via integrated assessments that trigger next steps based on results of a screening.
  • Empowering a care coordination staff member to make referrals to community partners, while the patient is still in the office to address their needs. 

 

More context around the concept of closed-loop referrals
  • What are they? In plain language, a closed-loop referral is one that successfully secures the right resources for patients at the right time, ensuring that the patients' needs are met.
  • How do they work? Care teams need confirmation that patients have seen the correct organizations for their needs. The "closed-loop referral" is a tech-enabled workflow that provides this real-time view of the status of the patient, while also exchanging data amongst the team, assigning tasks, and reporting on outcomes.
  • What information is shared? Closed-loop referrals can only happen in information rich environments where care teams can change the course of action, if needed. Referrals for social services can be fairly complex processes, involving many steps of action and diverse stakeholders. The stakeholders need to know basic patient information, the nature of the need to be met, and also the capabilities of other organizations in the network that may be better able to meet the patient's need.
  • How is the loop actually closed? Far beyond confirming the appointment was attended, a closed-loop referral includes workflow steps that help the care team to understand the outcome and, more importantly, any required next steps beyond the referral itself. This is why a care coordination network that integrates healthcare with social services is the most effective and sustainable method for implementing closed-loop referrals.

Closed-loop referrals exist within care plans in ACT.md

  • The ACT.md CareHub™ is a cloud-based care coordination platform that is designed to help your community network manage referrals, close the loop, and disrupt the cycle of vulnerability that causes many health and social needs in the first place.
  • Closed-loop referrals, by definition, are more than a one-way, one-and-done process involving a patient originating from a healthcare setting and ending up in a social services setting. Closed-loop referrals extend far beyond this linear model.
  • Closed-loop referrals depend on an often-overlooked capability for the referral process to originate in a healthcare setting and progress to a CBO, and then for the CBO to further refer the patient to another community-based organization which may be better positioned to help that patient, with the whole care team then being able to follow the referral through that process and any other redirects that may occur.
  • ACT.md has always been set up to be a technology that facilitates cross-community data sharing, not just clinical data exchange. This capability is increasingly called "community information exchange."

Community Care Coordination Platform

Security & Privacy

  • Your closed-loop referral platform must go beyond HIPAA compliance. ACT.md is built with very robust permission settings, which help to guarantee that your patient's data is not mishandled across a diverse network of providers.
  • ACT.md is also built with the capability to set customized security and privacy and use case policies.

Reporting & Analytics

  • Accessible data - ACT.md provides a tremendous amount of data that captures all the operational information related to the care coordination and customer and referral services that we offer. That data is accessible to clients on a secure server, that can be populated regularly.
  • Analytical capabilities - The vast amounts of data that we are able to collect that can be made available for internal analysis and the ability to cross reference that data with external sources of data to achieve real visibility into impact and outcomes.
  • In-tool reports - That allow you to keep track, in real time, the state of your managed panel (i.e. the people you're managing). Use In-tool report data to recommend interventions or tie outcomes to certain data conditions into an automated activity. For example, if a patient's risk score is very high and they recently had a hospital admission, that data can be used to trigger operational events.
  • Standard and custom reports - The standard reports are available immediately upon deployment. Custom Reports can be created with our professional analytics team and report writing team. We can find ways to create reports that will answer both operational and health outcomes related questions using the data that we provide.

Coordinated Healthcare and Social Services

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