Social Determinants of Health

The Potential of Integrated Person-to-Person Care and Technology

How to leverage community knowledge of person-to-person interactions with community social care technology to address health related social needs.


One of my most memorable rotations during medical school was a month-long pairing with a late-career general practitioner. He had been using the traditional written medical notes for years and was now transitioning to an electronic medical record. He was not resistant to the evolution of an EHR and actually saw the many benefits. What challenged him was how and where to put the years of knowledge he had accumulated - the intimate understanding of his patients' needs and who to call to solve these issues. 

There was no place for this profoundly valuable insight that had served his community so well for 40 years. In addition, even if he could use the EHR in this way, the people in the community he counted on did not have access and most likely would never use the EHR he was learning. In essence, this data was siloed in the brains of the individuals who made up the backbone of the community services.

Thirty years later, this was the challenge Activate Care faced in Nebraska: how to leverage the knowledge of community - of person-to-person interactions - while utilizing the best features of a community care record. It could not be one or the other. Both had important roles that needed to potentiate the work being performed for patients and families at risk. In addition, the data collected needed to both inform and then prove the value - both in human and financial terms of the work that was being done.

Technology can’t solve all the needs of healthcare. Neither the human element nor medical treatment of health issues can be solved purely by technological intervention. However, human effort and best intentions without technology support will never scale to full populations or provide the data to drive best practices. It is a combination of each, developed flexibly, which will allow for evolution and improved performance of both technology and human effort. This will drive the one thing everyone agrees upon - improved lives and health at the personal and community level.

The Path Assist program highlighted in a recent NEJM Catalyst article is the start of our contribution to solving this fundamental issue. We are excited to see how we at Activate Care will be part of the ongoing process of melding the best of both person-to-person care and technology. Let the journey begin.

Read the NEJM Catalyst article here

 

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