Community information exchange*, or CIE, is a community-based strategy for improving the delivery and integration of healthcare and social services. As its name...
A New Dawn for CBOs: Partners in Social Risk Management
There's a new dawn for community-based organizations (CBOs) in America. As many CBOs have become partners in efforts to address the social determinants of health, they have been asking how they can leverage their workforce to make the most impact in these efforts. The next question that follows is typically seeking to understand what technology options exist, and specifically how technology will make their teams more efficient, and allow them to do the best at what they want to do, and not be an extra burden on an already challenging process.
How CBOs participate in social risk management
One of the most interesting things that we see emerging right now is that these integrated community care models are being stood up outside of the traditional medical model. Leaders of these community care models recognize they need to be able to integrate and push their information back into healthcare systems and settings, to help better inform the care delivery that's happened inside the walls.
These programs - social risk management programs - take a longitudinal view into the individual, modifiable risk factors at play within a population. In partnership with entities at risk or sharing risk for the cost and quality of care, these programs typically deploy validated screening tools and a portfolio of social interventions against a person’s whole set of medical, physical, behavioral, and social needs.
Many times, CBOs and other local, non-medical service providers in the community haven't been pushed or had access to outcomes data. The ability to demonstrate their impact on overall cost of care or the results they're seeing has been severely lacking. And so what's been emerging over the last two years is the ability to quantify and demonstrate the impact and the overall value of those contributions to the integration of health and social services.
Starting with the end measurements in mind
For any CBO leader, a good place to begin is to explicitly outline what you are trying to measure. This may be defined for you by your funders. It may be suggested to you by your evaluation partners. What we know from SDOH programs that have been rooted in traditional medical models is that data is the currency of healthcare, and so being able to quantify impact, results, and contributions of a specific activity and organization is a mission-critical activity.
Sometimes organizations need to have operational metrics around caseload and case management activity, which demonstrates and enables efficiency with the professionals they're hiring. In other instances, it may be more traditional indicators such as medical expense ratio, looking at the impact of interventions against inpatient days, or visits to the emergency department. For specific interventions, many programs are looking the baseline likely outcome against the impact of the intervention, getting close to an aggregate measure of closing the loop.
When participating in these new models of care, Activate Care client organizations typically experience improvements in efficiency, effectiveness, and measurable outcomes, including a 30% increase in program capacity, 65% increase in client/patient engagement, 28% increase in community partnerships, and where clinical outcomes data are available, a 33% decrease in avoidable ED visits.