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.
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.
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.