systematic approach tracking - Camden Coalition · Regarding Systematic Approach To Managing Social Needs Of Patients. Key Finding Through interviews with hospital executives, Aunt

Systematic Approach To Manage Social Needs Of Patients

A look at the current state of the industry and best practices moving forward

By: Chris DunkinNovember 2016 

November 2016 Page � of �1 17

Table of Contents

Current State of the Industry 3Key Finding 3

Survey Methodology 3

Current Capabilities in tracking and measuring utilization of social-need based referrals 3

Perspectives on Social Needs in communities 4

Why does a systematic approach to connecting patients with social resources matter? 4

Where does the difficulty in implementing a systematic approach and tracking lie? 5

Conclusion 6

Best Practices for Social Need Referrals and Outcomes 7How Can Aunt Bertha Help? 8Complete Survey Results 9

Study Demographics 9

Need for social Help 10

Navigating and Tracking Referrals 12

Tracking Referral Outcomes 15

Expectations for the Future 17


Current State Of The IndustryRegarding Systematic Approach To Managing Social Needs Of Patients.

Key FindingThrough interviews with hospital executives, Aunt Bertha established that they recognize the need to address the social needs of their patients, but are not doing so in a systematic way because they lack the necessary tools and data.

Survey MethodologyAunt Bertha recently surveyed a sample of hospital executives through our partnership with GLG Social Impact. The survey assessed hospital executive’s perspectives on the role that community-based social services play in supporting their missions and their capacity to connect and track when these services are received. The survey included hospital CEOs, CFOs, COOs, CMOs, and Medical Directors. The survey respondents had no relationship with Aunt Bertha or the Aunt Bertha enterprise software. About 70% of respondents worked in community hospitals, with the remainder in academic hospitals. About 55% of respondents worked in hospitals with more than 250 beds, 30% worked in hospitals with between 100 and 250 beds, and the remainder worked in hospitals with fewer than 100 beds.

Current Capabilities In Tracking And Measuring Utilization Of Social-Need Based ReferralsThe survey shows that 95% of hospitals face difficulties with tracking and measuring utilization of referrals to social need-based agencies and 60% of hospitals do not have a solid tracking method in place.


5%

35%

35%

25%

Data is not trackedData is tracked poorly and decentralizedData is tracked, but with difficultiesNo problems tracking / measuring utilization

How well is utilization of such referrals tracked and measured at your hospital?

http://glgsocialimpact.com

Perspectives On Social Needs In CommunitiesThe need for help is not limited to the income level of the patient. While all hospitals had patients in need, more than 20% of population needs additional support at 63% of the hospitals studied. When hospital executives were asked how they would describe a patient population that needs social help, the reasons went far beyond income. A lack of caregivers at home, an aging population, a lack of support once a patient leaves the hospital, and a lack of knowledge of services available to help were all cited. Each patient population has a unique combination of needs that a hospital has to serve and monitor.

Why Does A Systematic Approach To Connecting Patients With Social Resources Matter?Hospitals are facing increasing pressure to focus on long-term clinical outcomes as quality measurement, pay-for-performance and other value-based purchasing strategies become the norm. In particular, the readmission penalties being applied by Medicare create substantial incentives for hospitals to take a more holistic view of the patient upon discharge, including addressing the social determinants of health.


The focus on addressing the social determinants of health is growing, and is expected to become increasingly important over the next 5 years. The survey showed that, 94% of respondents indicated it is important or very important to connect patients with social programs. Respondents also closely align connecting patients with social resources to their organizational goals. 50% of respondents indicated improvements in this area will be critical to their long term success and another 33% indicated that they will become more important. However, as the survey indicates, most hospitals do not have a systematic process for making these connections and little is being tracked.

The time spent finding resources matters as well for a busy care management team. A recent McKinsey study showed that employees spend an average of 9.3 hours per week looking for information. Until recently there were no consistent and systematic methods for hospitals to find community-based social service programs and track patient referrals to these programs, which leads to a resource burden.

Where Does The Difficulty In Implementing A Systematic Approach And Tracking Lie?Approaches implemented in the past by hospitals to address the social needs of their patients were informal and unstructured. Respondents indicated that the most common methods for identifying social services agencies were information maintained on personal lists and Google searches.


50%

17%

33%

Will become more important Will have about the same level of importanceWill be critical for our long term success

How do you expect the importance of the ability to connect patients to agencies that can address their social needs to change over the next 5 years?

Despite significant awareness of patient needs for social supports by hospital executives, more than 70% of respondents indicated that they either had a process for making referrals to social service agencies that was not systematic or that they had a systematic process that was underutilized. About 60% of respondents indicated that utilization of referrals to social services was either not tracked and measured at all, or was tracked poorly and in a decentralized fashion. An even higher percentage (about 65%) gave the same responses with respect to the tracking of outcomes from referrals to social services.

The most common explanation for not providing more navigation services to social programs was that it takes too much staff resources. In addition, more than half of respondents identified the lack of software or a tool to find resources as the primary reason for not having a more systematic approach to tracking social needs support.

ConclusionHospitals are anticipating an increased demand for a systematic method for generating and tracking referrals to programs that assist patients with social needs, but a lack of staff resources and lack of implemented software are challenging hospitals capabilities implement these processes.


30%

43%

27%

The systematic process exists, but is underutilizedWe have a referral process, but it’s not systematicWe have a well-utilized, systematic process

Does your hospital have a systematic process to make referrals to such agencies?

Best Practices For Social Need Referrals And OutcomesHospital executives recognize the need to address the social needs of their patients but are not doing so in a systematic way because they lack the tools and the data they need to support their efforts. There are great advances in these capabilities, and the following best practices should be in place as part of any systematic approach for making referrals and tracking outcomes:

• Have a centralized system that makes it easy to find social program resourcesCare management teams are extremely busy, so any new solutions must be easy to use and save time or there will be challenges with user adoption. Making sure a solution is easy to use will not only promote adoption among a care team but also allow more staff members, such as front desk staff at a provider’s office, to help navigate patients to resources as well.

• Make sure program data is up to date and accurate. A social program database must have depth of agency listings and be up to date and accurate. This will also promote adoption and usage of the solution and avoid situations where trust is lost with the patient if a referral is made with inaccurate information.

• Empower patients to self navigateThere will be times when a patient has a new social need that happens when they are not engaged with a staff member. There may also be sensitive needs with relation to human service needs that patients are not comfortable sharing with hospital staff. Empowering patients to self navigate solves these challenges and still allows for information to be collected on human service needs.

• Collaborate with the social program agencies you are referring patients toNonprofit and government human service agencies have their own missions and goals, many of which align with the missions and goals of hospitals. Both have missions that center on helping people in need to achieve better outcomes. Collaborating with local agencies to refer patients into can help in meeting patient’s humans service needs and in some cases help with referrals tracking.

• Create reporting that shows which referral activities are impacting outcomesA centralized human service referral system can provide a wealth of data that includes specific areas of human service needs for your patient population, which agencies are being referred most often and how many times they were able to provide help, and which employees are regularly making referrals. Tying this information to patient health data can show which human service activities are having the greatest impact, guiding best practices for staff members.


How Can Aunt Bertha Help?

Aunt Bertha’s software for hospitals and health plans helps to more effectively and efficiently connect patients to agencies that assist with food, housing, transportation, and other services. This provides a quick and consistent process for social program referrals.

All activity is recorded so referrals and areas of greatest need for a patient population can be seen in real time in our analytics dashboard, allowing executives to spot trends, gaps, and which social interventions have the greatest impact.

For a demonstration, please visit about.auntbertha.com/demo-request or contact [email protected] or 512-522-9549


http://about.auntbertha.com/demo-requestmailto:[email protected]?subject=

Complete Survey Results

Study Demographics  

What is your role at the hospital?

How many beds does your hospital have?

What type of hospital environment do you work at? 


3%

47%

10%

25%

15%

Chief Medical Officer Hospital CEOHospital COO Medical DirectorVP of Case Management

12%

13%

5%

37%

30%

3%

1,000 – 1,500 beds 101-250 beds251-500 beds 501-750 beds751-1,000 beds Fewer than 100 beds

27%

73%

Academic Hospital Community Hospital

Need For Social Help

In a few words, how would you describe a patient population that needs social help?

Based on the definitions you provided, what percentage of your patient population meets this criteria and needs “social help”?


28%

18%17%

37%10-19%20-29%30-39%40% or more

Big picture, how important is it for your hospital to connect your patients with free or reduced cost social programs to help with things such as food, housing, transportation, or substance abuse treatment?


53%

15%

17%

10%

3%2%

Not important23456Very Important

Navigating And Tracking Referrals

Does your hospital have a systematic process to make referrals to such agencies?

How well is utilization of such referrals tracked and measured at your hospital (for example, how many times employees searched for food programs)?


30%

43%

27%The systematic process exists, but is underutilizedWe have a referral process, but it’s not systematicWe have a well-utilized, systematic process

5%

35%

35%

25%Data is not trackedData is tracked poorly and decentralizedData is tracked, but with difficultiesNo problems tracking / measuring utilization

In general, how do employees at your hospital find agencies that provide help with social needs when that need is identified?


Google searches

Personal employee lists

Sharepoint Database -Updated rarely

Sharepoint Database -Updated frequently

211

Social Workers

Community Databases

Local Resource Clearinghouses,such as MHMR

0 17.5 35 52.5 70

The systematic process exists, but is underutilizedWe have a referral process, but it’s not systematicWe have a well-utilized, systematic process

Why, in your experience, does your facility not provide more navigation services to social programs like the ones described earlier?


% of Respondents 0 17.5 35 52.5 70

Not in alignment with financial objections Time consumingTakes too much staff resources

Tracking Referral Outcomes

How are outcomes for such referrals tracked and measured at your hospital? (For example, Jane Doe was referred to XYZ Housing program, where she received assistance.)

What are the primary reasons why your facility doesn’t have a more systematic approach to tracking social needs support?


8%

50%28%

15%

It is not trackedIt’s tracked fairly well, but with some difficultiesIt’s tracked poorly in a decentralized fashionWe have no problems tracking and measuring utilization

55% 35%

10%

Best practices are not being enforcedBest practices haven’t been developedLack of software or tool to find resources/track actions

To what extent is the executive team aware of these activities related to navigation of patients to social programs?

To what extent does your organization proactively ask questions to patients to identify social needs, such as food availability, housing, transportation, or substance abuse treatment?


22%

58%

10%10%

No visibilityThey have real-time visibility into such activitiesThey know high-level information, but aren’t familiar with the detailsThey receive detailed reports at regular intervals (either semiannually or quarterly)

13%

43%27%

17%

All the timeFrequentlyRegularlySeldom

Expectations For The Future

How do you expect the importance of the ability to connect patients to agencies that can address their social needs will change over the next five (5) years?


50%

17%

33%

Will become more important Will have about the same level of importanceWill be critical for our long term success

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systematic approach tracking - Camden Coalition · Regarding Systematic Approach To Managing Social Needs Of Patients. Key Finding Through interviews with hospital executives, Aunt