CareAllies and VOP designed a pilot program to use data and analytics for proactive outreach to patients believed to have unaddressed social needs, while simultaneously fielding referrals from physicians. The pilot, now a fully-implemented program, focuses on key SDOH areas to bridge the gap between patients and relevant resources and relies on CBOs and other partners to maximize access. Key areas include: food access, housing, financial assistance, social support, health education, psychosocial needs, and transportation.

The first step of a successful SDOH support program is to identify who in the population needs support—which can be more challenging than anticipated. CareAllies’ program finds VOP patients with SDOH issues by utilizing multiple sources of data and engaging in conversations at the point of care. Data and analytics are used for proactive outreach within VOP’s patient population, and physician-patient conversations lead to additional program referrals, which is an improved version of many common SDOH programs.

Referral-driven outreach

The CareAllies team fields referrals from internal sources like case managers, pharmacists, and medical directors, as well as external sources, like a patient’s PCP, who is seen as a key referral channel. CareAllies encourages VOP’s clinicians to utilize screening tools (like PRAPARE) to identify SDOH needs and to inform patients of the CareAllies outreach. While patients may be suspicious of “out of the blue” outreach, they are more likely to accept help if their trusted PCP informs them of the call beforehand. This is a central concept to CareAllies’ program: build on trust where it already exists.

Once a PCP screens a patient, they can use referral tools from CareAllies to connect the patient to the Health Advocate Team. Once the patient has been referred into the program, a CareAllies Health Advocate contacts the patient to perform a teleassessment designed to identify additional barriers and score patients based on SDOH needs and risk. The assessment helps the program’s staff better triage patients and link them to the appropriate interventions.

Proactive outreach

CareAllies also developed a proactive outreach system for patients with needs that aren’t detected through interactions with clinicians that identifies who might need help overcoming their SDOH barriers.

The CareAllies Health Advocate Team developed this proactive outreach approach for several reasons. For PCPs, conversations about social needs can be difficult, taboo, or time-consuming, which makes it challenging to identify all patients with SDOH-related needs. In addition, patients may be hesitant to speak to their PCP about their needs or may not go to the PCP’s office at all; hence, many issues may go undetected.

In order to conduct this proactive outreach, CareAllies created a Whole Person Health Score algorithm used to prioritize patient outreach and predict success.

The scoring algorithm is based on three main data sets: geographic information, individual data and future cost considerations. Not surprisingly, financial and economic factors play a significant role in the algorithm.

An analytics team is equipped to monitor data flows and identify appropriate outreach targets. This team identifies patients with predicted SDOH needs and stratifies these patients by their overall whole person health risk.

After identifying patients with social needs, the CareAllies team helps resolve their needs by educating them, sharing resources, and referring them to community resources.

The program is operated by the Health Advocate Team, an interdisciplinary team of social workers, registered nurses, dieticians, licensed practical nurses, health equity consultants, pharmacists, and data and analytics experts. The program’s staff stresses cultural competency. Crucially, staff is hired from the community and many speak Spanish to accommodate nearly 90% of the population that identifies as Hispanic in Hidalgo and Cameron counties.

The teleassessment performed when patients are referred into the program mirrors existent screening tools like PRAPARE and helps glean more information for CareAllies and VOP to improve patient outcomes.

There is no “typical” case in terms of length or intervention, given that every patient has a unique set of needs that will need to be addressed. Generally, once the Health Advocate Team reaches out to a patient, connects the patient to a CBO or other resource, and confirms they’ve addressed the root problem of a patient’s SDOH issue – the case is closed. Should new SDOH needs arise in a patient who’s already gone through the program, a new case will be opened.

The program focuses on linking VOP patients with local resources in seven categories: food access, housing, financial assistance, social support, health education, transportation, and psychosocial needs.

A real case example gives greater understanding of how the CareAllies interdisciplinary team works in action.

Jane’s PCP was able to identify a barrier that could have been overlooked by data and analytics without considering the human perspective. In addition, CareAllies’ interdisciplinary staff experts were able to dig deeper, identifying additional barriers. By working together, utilizing both data and the physician-patient relationship, the SDOH program has a more significant impact on health outcomes for VOP patients.

CareAllies closely tracks patient outcomes and coordinates follow-up care with the patient’s PCP. The goal of the program isn’t just to connect patients with resources, but to also monitor the whole health of a patient and ensure referred resources are utilized properly.

CareAllies gathers a myriad of data points throughout the care journey to optimize outreach and treatment of those patients in need, and then ensure those needs are being met. For example, the program carefully tracks the length of various processes throughout a patient’s care journey, from the identification of a need, to successful utilization of resources. This information is used by CareAllies to help identify trends and learn what works and what doesn’t, while establishing stronger relationships to better meet the needs of patients.