Interoperability 2.0 – Creating a Holistic Model of Care Part 3

Published on
Thursday, April 19th, 2018

AUTHORS: Eric Crawford, Director of Product Management, and Adam Bell, Senior Director, Advisory Services Department

Part 3: Innovation through Workflow Integration

The SDoH burden score helps healthcare providers to understand holistic population profiles so that care providers can better address the needs of a population. In order to be truly effective, these profiles need to be available to the front-line, multi-disciplinary care team for the population being served.

Companies can create beautiful UI’s and detailed dashboards; however, if these tools are not aligned to workflow with a clear benefit, the tools may as well not exist.  The best tools are directly aligned to workflows of the care providers.

By bringing multiple data sources together at the point of care, organizations can truly begin to understand and improve the care experience for individuals (e.g. quality and satisfaction), improve the health of populations, and reduce health care costs.

Innovate Solutions and Integrate with Multi-disciplinary Team Workflow

A PCP typically spends between 13-16 minutes per person with a primary focus on “diagnose and treat.” Care Managers often focus on smoothing out transitions and providing coaching on healthy behaviors. It’s difficult for the care team (ex. PCPs and Care Managers) to provide holistic care because time is limited and there are lack of resources to curate a list of community resources to address social factors. Furthermore, the information is often not easily accessible when it’s most needed or while the patient is present.

In order to bring social determinant interventions to the front-lines, it requires a change in thinking. This includes making it easier for the multi-disciplinary care team to have critical information to address a person’s potential SDoH needs through use of actionable analytics.

The results of the analytics must be tailored to the needs of each person and easily accessible to the care team within their workflow. This is essential to creating a holistic model of care and interventions that address social determinants of health.

Embrace Data Driven Continuous Quality Improvement (CQI)

Success comes from being able to try, fail, learn and grow whether the focus is social determinants or other categories. Embracing holistic model of care development and a learning health system mentality ultimately increases the likelihood of getting more of what you want: safe, efficient, effective care.

Please contact to learn more about our journey into leveraging social determinants and creating a holistic model of care.

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