Understanding the Challenges of Coordinating Care Around Social Needs



In recent years, we have seen significant shifts in the way we manage health in the U.S. As reimbursement models transition away from fee-for-service to value-based, there has been an increased focus on innovative models of care that integrate non-medical health factors such as food, housing, and transportation. These factors are often referred to as the social determinants of health (SDoH) and can account for up to 80% of our health. According to a 2017 report by the Deloitte Center for Health Solutions, 88% of hospitals are now screening for social needs. Also, the most recent Change Healthcare Annual Industry Pulse Report reveals that more than 80% of payers are already taking steps to promote value-based healthcare by addressing the social needs of their members.

Most healthcare systems now understand the urgency of developing strategic initiatives that address their patients’ unmet social needs to drive down costs and improve outcomes. The predominant question is, how to identify and remove the barriers that exist when building the infrastructure and support needed for holistic care delivery.

Understanding the Challenges

The first step is understanding the problem. Earlier this year we introduced the “Social Needs Funnel,” Healthify’s framework for helping healthcare organizations shape how they measure SDoH investments. The Social Needs Funnel can also be used to understand some of the challenges healthcare organizations must navigate as they develop strategies to address the social determinants of health. 

1) Low Visibility and Lack of Prioritization 

Social need assessment tools now make it possible for healthcare systems to quickly screen for and identify the health-determinant needs of individual patients, but low visibility into which social needs a population has and/or who is most at risk makes it difficult for healthcare leaders to prioritize interventions or allocate appropriate resources.

2) Inability to Find the Right Resource/Interventions

Those on the frontline of care delivery (case managers, providers, and social workers) must often sift through dozens or even hundreds of social services within a community to find the right type of service for their patients. Additionally, the lack of visibility into the status, reliability, eligibility, and intake requirements of a social service organization adds unnecessary costs and burdens in addition to the time-consuming process of finding accurate and reliable information to support patients.

3) Fragmentation of Service Delivery

Even if a healthcare organization can identify and refer patients to the right resource(s), there is often no visibility into the success of the referral. As separate entities, with distinct workflows, healthcare systems and community-based organizations (CBOs) lack the transparency and communication channels necessary to coordinate efficiently. Care teams are often left wondering whether or not a patient did, in fact, receive the intended services.

4) Lack of Transparency and Accountability

Finally, the opaqueness of the standard referral process and absence of accountability, between the healthcare system and CBOs, within care coordination makes it difficult to understand the ultimate impact of social service interventions on outcomes and costs.

Navigating the Challenges and Moving the Needle

To succeed in this new value-based setting and deliver a robust social needs strategy, healthcare systems must overcome the numerous challenges of holistic care coordination. Critical steps include: developing the right workflows and creating shared accountability with community partners and identifying the right teams and tools to help support an environment that produces a more cost-effective delivery system that creates opportunities for improved outcomes.

Join us live on Tuesday, March 20, at 11 AM PT/ 2 PM ET, for an in-depth review of how to address the challenges of coordinating care around your social needs. Manik Bhat, CEO and Co-founder of Healthify, and Rishi Manchanda MD MPH, President and Founder of HealthBegins will share expert advice on how to set up a social needs strategy for your organization to improve care and reduce costs. The live webinar, Moving the Needle on Patient Outcomes Through Upstream Care, will include a Q&A session.

If you’re unable to join the live event, register and a recording of the webinar will be available on-demand following the live event.

Register Now


Topics: webinar care coordination

Related posts