Covid-19 has underscored in stark terms, that where we live, learn, work and worship affect how the pandemic impacts a community. Individuals in urban settings, people of color and those affected by disparities suffered far more disease prevalence and mortality than other populations. According to The Robert Wood Johnson Foundation Commission to Build a Healthier America our zip code impacts our health and future wellbeing more than our genetics. There is ample research to suggest that social determinants of health (SDOH) factors may contribute to as much as 50-60% of a person’s healthcare costs. Yet the use of technology to bridge this gap has been narrowly deployed and meeting these needs, once assessed, is often poorly executed. This brief article covers how technology can be leveraged to engage underserved clients to address their social needs during the pandemic.
Managed care plans have begun to deploy technology and people to address this issue. An example is a partnership between Blue Shield Promise and LA, two health plans opened their first joint resource center in December of 2019. Like LA Care’s other community resource centers, this site connected members with local resources to address social determinants of health needs. Both health plans had staff on location to support members. During the pandemic they pivoted to offering social determinants of health resources and wellness programming online during the shutdown1. More plans have begun to deploy these forward-thinking efforts.
It was our organization’s goal to use a business intelligence approach to address the disparities present in our community by deploying technology solutions. In July of 2019, our IT team created our own SDOH app that the partners named “WeSource”. Less than a year after deploying our solution COVID-19 hit and we quickly realized it was more important then ever to double down on this strategy. Like other boroughs, the underserved and minorities were affected most critically. Our community had the highest prevalence per 100,000 residents of any borough of New York City. We quickly realized that many of the 130,000 clients we needed to serve suffered from substandard housing, poor economic and educational opportunity, violence in their neighborhoods and food insecurity along with a host of other social issues. Many had to continue to work during pandemic at in-person jobs thrusting them into harm’s way on public transportation and in frontline jobs in nursing homes, hospitals, transit and public service roles. Throwing money at such a monumental problem was not the answer if we could not align community-based partners to meet the needs and fund them to provide services.
Just as referenced above in the LA Care’s example, it was important for us to be able to screen, refer and manage profiles that we could merge with client’s clinical data to create a 360 view of their situation. The help of social service agencies, partners in the community and local government agencies and their feedback is essential as these agencies have the trust of the underserved. In an era when immigration, racial and social unrest is prevalent, engaging community-based organizations (CBO) that have trusting relationships with their clients to perform this work is essential. Many CBOs’ however, have limited technology capacity, funds to invest and staff with IT skills. The IT team incorporated simple functionality that was important to them so that the app was useable and can connect individuals in need, to local services, allow for follow-up to close the loop of the referral and feed responses to the electronic health record of the client. In a few short months over 20,000 families were served, 300 who were homeless!
The use of simple, inexpensive, and scalable technology was critical as was a tool that could be used in the field with virtual training for frontline staff. The strategy associated with this tool is to have navigators checking for needs and then instantly connecting people to resources on-the-spot, so there is a better chance of people getting the right help in timely way. To follow-up on interactions, we deployed other cost effective technology solutions, a chatbot and texting platform so we could engage individuals and avoid unnecessary and risk physical interactions that could spread the virus and endanger clients and providers alike. The chatbot feature was a huge hit with clients and multiple iterations were deployed to address evolving topics. Other iterations and technology choices were effectively deployed in diabetes management and behavioral health virtually connecting these high-risk clients with their clinicians. From a population health standpoint these programs were extremely successful. The data collected from this program has helped determine evolving and most pressing health factors affecting neighborhoods. The ability to do periodic surveys of large segments of the community allows for snap shots of evolving needs, recruitment of new partners and enhances the quality of analytics. We have also begun sharing this information with the client’s consent, with our regional Health Exchange, HEALTHIX so the data is available to other organizations providing medical services to incorporate into their care plans. This formula can be replicated in organizations throughout the country and is literally a life saver for those in need.
Innovation has been a major driver in leveraging population health efforts in the battle against COVID-19. Using technology creatively has enabled providers to cost-effectively engage clients and prevent costly, avoidable emergency room and hospitalizations utilization.