Beyond the Four Walls: Using Technology to Address Your Patient’s Social Determinants of Health (SDOH) Needs

The following is a guest article by Hannah Landes, Senior Associate at NowPow, and Niko Skievaski, Co-founder and President at Redox.

The U.S. healthcare industry has made a big investment in moving to a value-based care model, both in terms of reimbursement structure as well as medical practice. Implementing this model means that providers have more responsibility to make sure that their patients are following medical instructions.  However, many patients leave their doctor’s office only to run into hurdle after hurdle in an effort to stay healthy. Addressing a patient’s social determinants of health (SDOH) needs, such as access to healthy food, transportation to medical appointments, the pharmacy or the supermarket, and air quality, is critical to implementing successful interventions and making sure people receive the full value of medical care.  

But how do you manage a patient’s care once they’ve left the four walls of your facility?  

This is a critical topic, and we’re pleased that Colin Hung and John Lynn think so too, as we’ll be talking about this on August 1 at Expo.Health. During the presentation, we’ll showcase how integrated technology can be used to address patients’ SDOH and support the human connection between patients and providers to create a better healthcare experience.

Every profession and industry develops ways to track its moving parts and this holds true for the field of medicine. Though caregivers have been recording patient interactions, prescriptions and treatment plans long before modern technology, electronic health records (EHRs) have become the new standard for keeping medical care organized. 

While EHRs help health systems stay organized internally, they do little to help clinicians track, organize and access technology outside of their system. This can be a problem when it comes to referring patients to other hospitals and specialists, as clinicians need to be aware of what resources within the community are available to patients in order to provide the right care. Without thorough and accurate knowledge of what help is out there, clinicians may refer patients to the wrong specialist, leading to unnecessary complications, delay of healing, and waste of health system resources.

Community Connection

The widespread need to provide clinicians with an accurate list of outside resources is why NowPow exists. NowPow’s software aggregates community resources into an up-to-date and comprehensive list so care providers can connect patients to the right people to help them address all sorts of chronic health and social conditions. This ability, while seemingly simple, gives care providers the power to expand the scope of their care and deliver the best possible treatment plans to patients.

Awareness of resources is as important to actually using them, and within one program, NowPow allows care providers to see all available local health specialists, current community fitness class schedules, the locations and hours of family planning clinics and so much more. Continuously updated by an in-house team, NowPow’s database can be accessed and updated by clinicians too. NowPow also lets care providers create a resource listing, called a HealtheRx, that contains details on a resource’s location, services, specialists and hours. This referral description can then be sent to patients directly via text or email to brief them on where they’ll be continuing treatment and with whom.

More Than a Database

Closing the loop on communication, NowPow also allows the care provider who created the referral to contact the resource to which they were referred. This functionality helps care teams know whether or not patients are following through with outside appointments and staying true to their care plan. Both the primary caregiver and the outside referral resource can use a functionality called Nudge to remind patients about appointments or to take treatment actions. All of these features not only give providers peace of mind that their patients will comply with a care plan, but it also reduces time spent on communicating, coordinating and documenting care and more time tending to patients’ needs.

Beyond a resource database, NowPow offers a bi-directional communication platform that allows both patients and providers to send and be alerted of messages in real-time. The patient engagement timeline functionality also records all interactions throughout the care journey so that every provider on the care team can stay informed of how a patient is progressing.  

Interoperability Powers Better Data Exchange

NowPow uses Redox to integrate with EHRs used at hospitals and clinics. By integrating into the same system used by clinicians, NowPow’s application can function as part of the same referral workflow clinicians use. There’s no need to log communications between providers, record attendance for outside appointments or double document referrals. By documenting it within NowPow, that information is automatically filed into the EHR in real-time, allowing care providers to view the most comprehensive and updated information on a patient’s care journey and better coordinate care. 

Today, NowPow helps generate thousands of referrals to community resources. Clinicians don’t have to spend time researching or sifting through specialists. All of this enables care providers to stay aware of community resources and close gaps in care. This is a prime example of how healthcare organizations can adopt a technology solution to offer more cohesive care for patients. The goal is to ensure patients with limited resources receive the right care at the right time, and have a path for good health long term. While healthcare outcomes success can be measured by what happens within a hospital or health system, the industry’s future depends on the quality of care and technologies that enable clinicians to treat patients beyond those four walls. 

Redox is a proud sponsor of the conference.