It’s no secret that much of the declining healthcare in the United States today can be tied to a series of complex physiological, social and economic issues that are present in impoverished communities throughout the U.S.

In fact, a study by the Robert Wood Johnson Foundation indicates that “Four in five physicians say patients’ social needs are as important to address as their medical conditions… [and] for physicians serving patients in low-income communities, nine in ten physicians believe this is true.”¹

The Impact of Non-Clinical Factors on Healthcare

The non-clinical factors that impact an individual’s healthcare can include a host of influencing factors such as access to housing, job status, family support, nutrition, community safety, diet and exercise, access to child care and many other factors — even the ability to pay a monthly heating or electricity bill on time can have an immediate and long-lasting health-related impact.

Because many impoverished patients have very complex social, socioeconomic and psychological needs, it can be challenging for traditional healthcare systems to meet their needs — and they can become what’s referred to as a “frequent flier” or a “high utilizer” in many hospital emergency rooms across the U.S. 

For instance, a recent program at the 872-bed Parkland Memorial Hospital in Dallas, TX, (one of the 10 biggest hospitals in the U.S.) has seen a surge of high utilizers, identifying as many as 96 patients who had visited the hospital at least 10 times in one month, some running up unpaid bills of over $100,000. In fact, the hospital spent a staggering $871 million on uncompensated care in 2016. ² These frequent fliers not only overcrowd emergency rooms and increase wait times, but they also put financial strain on the healthcare system, and in turn impact other patients, without addressing the underlying needs of those high utilizers.

Hospitals across the country are desperately looking for proactive solutions to address this issue. In fact, Parkland Memorial has aggressively developed a system of integrating healthcare with community services in an effort to reduce high ER utilization rates and drive down costs. 

The Robert Wood Johnson Foundation study referenced above also underscores this desire by physicians to help their urban and low-income patients. The study found that three out of four physicians surveyed wished that the healthcare system would pay for the costs associated with connecting patients to services that address their social needs; including the ability to write prescriptions for non-traditional prescription items like employment assistance, adult education and housing assistance. ³

The Challenges in Connecting Patients to the Resources They Need

As hospital systems and emergency rooms are facing mounting pressure to improve healthcare outcomes, while at the same time cutting costs, many are looking for ways to better connect their patients with the community resources that they know will help their social determinants of health and, in turn, improve their healthcare outlook. 

The challenge is that if a hospital has a social team on staff to conduct a mental or social health assessment, many do not go deep enough to truly identify an individual’s needs. For example, a traditional assessment may only have 5-10 questions, such as “Do you need assistance for housing?” or “Do you have enough food to eat?” These questions typically aren’t able to identify an individual’s true needs — nor can they effectively rank-order the most critical needs that will help move an individual to self-sufficiency.

As RiverStar has worked with multiple healthcare and community-based organizations, we’ve developed a system that’s been proven to not only identify an individual’s needs, but to connect them with the resources they need to improve their situation — and, in turn, reduce the overall weight on the healthcare or social service organization.

RiverStar’s 3-Step Process for a Successful Care Plan

Step 1: Screening

The RiverStar solution follows a 3-step process, starting with a HIPAA compliant health and wellness screening. This provides validated results to diagnose and pinpoint issues related to social determinants, behavioral health and/or substance abuse. The screening not only covers the 19 Social Determinants of Health domains in the Arizona self-sufficiency matrix, but it also covers additional domains related to healthcare costs, literacy and the cost of utilities. 

To complete the screening, a nurse practitioner, case worker, care navigator, or other care provider guides the patient through the questions, which are are phrased in an easy-to-understand fashion, protecting the patient’s dignity and increasing the likelihood of honest answers.

This screening process provides an incredibly detailed snapshot of the patient and outlines areas of assistance required for the development of a care plan. What’s more, the areas of need are prioritized to develop a triage of urgency — ensuring the most critical needs can be taken care of first.

Step 2: Resource Matching

Equally as critical as identifying the patient’s needs is matching the patient with the resources needed to get help. This is the second step of the process, and because the screening identifies needs at a very precise level, patients can be immediately matched with community resources via a searchable database. Once a resource is identified, referrals can be made on-the-spot, eliminating the possibility of the patient being released and never following through on the appointment setting.

Step 3: Continued Monitoring

Finally, the third step of the process involves the ability for the nurse practitioner to follow up with each resource. The RiverStar solution includes the ability to:

• Close the loop on referrals that were made
• Ensure needs have been met by referred agencies
• Schedule additional resources as needed
• Annotate each referral
• View and track results
• Manage additional resources in the future as the patient’s situation improves or as needs change
• Share information with internal departments, other practices, or other members of the person’s care team quickly and easily

As private practices, hospitals and emergency rooms seek to improve care while simultaneously driving out unneeded costs, the challenge of high utilization rates must be addressed. By helping connect patients with the community resources they need and pairing those resources with best-in-class healthcare, we can help bridge the gap between healthcare and social determinants.