Integrating Social Health Data to Improve Care Delivery

May 1, 2018

When you arrive as a new patient at one of 11 clinical sites at the Denver, Colorado-based Metro Community Provider Network (MPCN), you’ll find that alongside a discussion of your medical history, you’ll answers questions like, “Do you have adequate food? Adequate housing? Are you comfortable discussing your medical needs with your provider?” Your answers to these important questions about essential social needs directly into your electronic health record, just like any other medical vital. If any critical needs emerge during your visit, patient navigators are on hand to meet with you to discuss resource connection options.

MCPN aggregates the social needs data collected at these appointments from across the sites and analyzes it in conjunction with health data. By treating social health data reporting with the same rigor as other key health outcomes, MCPN has shown a 10 % increase in appointment attendance among those enrolled in the navigation services.

Yet, like so many other health systems that I’ve worked with at Health Leads, their initial pilot started at a much smaller scale.

At the outset, when the Federally Qualified Health Center (FQHC) first launched its pilot, their goal was to build leadership and physician buy-in with very limited resources by collecting the data that proved the extent of the need. Armed with an Excel spreadsheet, the team set out to better understand the scope of their patients’ needs. After establishing the baseline need, they recognized that to achieve the whole-person impact they were seeking, they needed to find answers to new questions that were emerging:

  • Were patients’ missed appointments caused by struggles to find child care?
  • Was local public transportation interfering with people’s ability to access care?

Without answering questions like these, how could staff know what work to address patients’ essential needs was most positively impacting patients’ health?

Allison Draayer, a consumer care services manager at MCPN, shared that, “You get into the work because you know that it helps, but you need the data to support it. It can’t just be the ‘right thing to do’ – it has to be productive.”

MCPN made its essential needs strategy productive with a shared commitment to data collection and reporting. Through continuous and ambitious learning efforts, the team at MCPN has begun capturing important social and health metrics that enable them to see the impact of their programs directly in their electronic health records. They continue building buy-in for expansion through the dissemination of a monthly dashboard to leadership and staff incorporating social health metrics such as the number of resource connections, changes in missed appointment rates, health outcomes and patient impact stories.

We’re excited to showcase MCPN’s commitment to more explicitly measure whole-person impact in this new case study, Integrating Social Health Data To Improve Delivery and Address Social Needs. The case study is full of insights on data collection, building and supporting care teams, and quantitative and qualitative reporting.  Among MCPN’s advice:

  • Fully integrate SDOH data into your electronic health records. MCPN could only start analyzing the impact of social needs on health outcomes by integrating the PRAPARE Electronic Health Record screening template into their Centricity EHR. For the best insights into impact social needs data had to be directly combined with health data.
  • Incorporate patient voices into service delivery improvement efforts and reporting. Getting caught up in data can depersonalize the impact. Incorporating patient voices makes the work feel more personal and powerful. At MCPN, patient stories are incorporated into their monthly reporting dashboard and a patient advisory council informs delivery improvement and shape
  • Empower social needs workforces through robust training and coaching. To support patient navigation and care coordination staff, Patient Navigators complete training courses on navigation and motivational interviewing during their first year of employment.

When we checked in with MCPN, we were wowed by how they have scaled their efforts after integrating social health data into their electronic health records. Dive into the full MCPN case study to learn more about their current pilots, including risk stratification and success metrics.

Read the Full MCPN Case Study


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