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New Digital Tool Closes the Loop, Helps Clinicians Follow Up on Patient Care Referrals

Dec. 14, 2021

AUSTIN, Texas — For people with low income seeking medical care from community clinics, a visit to see a health care provider can also be an opportunity to connect with supportive social services. These critical local services — available through community organizations working beyond clinics and hospitals — provide resources such as ridesharing, food assistance and temporary housing that are key drivers to improve health. But when clinicians make social service referrals, it’s difficult to know whether patients access those services, and if so, to what extent they were helpful.

In collaboration with community partners, a team of population health researchers at Dell Medical School at The University of Texas at Austin is leading the development of a two-way digital platform enabling clinicians and social service providers to close the referral loop by communicating whether, and how, local resources are accessed after a patient’s clinic visit. For the 56 million Americans with limited access to primary medical care, this effort will help support a system of whole-person care in which providers and support service organizations can collaborate to improve the health of individuals who are part of the most vulnerable communities.

For example, a patient with diabetes who has a challenge accessing fresh, healthy foods to help control her blood sugar level may be referred by a clinic to a nearby food bank. With the patient’s consent, the new closed-loop referral system would ensure that the patient information is sent to the food bank and received back from the food bank if the needs of the patient were addressed after the referral. The system is compliant with the Health Insurance Portability and Accountability Act (HIPAA) to ensure patient privacy is maintained while information is exchanged.

Similarly, asthma attacks can be triggered by home conditions, including environments with smoking, pets, mold or roaches. If such conditions are identified during a clinical visit, for example, the clinician may refer the patient to a social service organization to evaluate the situation and provide a solution for the patient to address asthma triggers in the home.

“The digital system we are testing will make it easy and efficient to share all this information seamlessly between health and social service providers, and help coordinate care for patients by tracking whether their needs were appropriately addressed,” said Anjum Khurshid, M.D., Ph.D., associate professor and director of data integration in the Department of Population Health at Dell Med, who leads this work. “The system is designed to avoid adding to the burden on service providers, and to help patients navigate the health system easily.”

Collaboratively Creating a Replicable Model

The initiative is part of a two-year, Dell Med-led program with community partners to create a scalable, widely replicable model that can ultimately allow clinicians in and beyond Travis County more comprehensive access to relevant patient information in a seamless, secure way that does not interrupt clinical workflows.

This work, funded by the Office of the National Coordinator for Health IT (ONC), is designated a Leading Edge Acceleration Project (LEAP) in Health IT. The goal is to advance health equity and improve health by integrating information about the social determinants of health – the conditions where people live, work, play and age that affect their health – with clinical information.

The program is being piloted in collaboration with People’s Community Clinic, a federally qualified health center, and Integral Care, Travis County’s mental health authority. Other local partners include Integrated Care Collaboration, a nonprofit health information exchange organization, as well as the social care directory and referral providers Findhelp (formerly known as “Aunt Bertha”) and UniteUs.

“When we identify a social driver of health, the process of connecting a patient with resources can be challenging, and we rarely know if the connection actually occurred until the patient returns for their next visit,” said Louis Appel, M.D., MPH, chief medical officer and director of pediatrics at People’s Community Clinic. “This new project promises to not only streamline the information and referral process for our clinical staff and patients, but also will help the clinical team know that the patient has successfully connected to the resources they need.”

The second year of the program will focus on demonstrating the program’s scalability and replicability in other communities and will include collaborations with health information exchange programs in El Paso and New Orleans. Once the model’s feasibility is demonstrated, Khurshid’s team will design a nonproprietary toolkit that can easily be adapted by communities across the nation.

“We know that when care is fragmented, it leads to greater burden on the patient, higher costs and worse outcomes,” said Maninder Kahlon, Ph.D., vice dean of the Health Ecosystem. “This type of collaborative program integrates and centers on the needs of a patient, be they best served in – or out – of the clinic, in the landscape of life,” she said.

NOTE: This project is supported by the Office of the National Coordinator for Health Information Technology (ONC) of the U.S. Department of Health and Human Services (HHS) under grant number 90AX0033, “FHIR-enabled Social and Health Information Platform (FHIRed-SHIP): Integrating a closed-loop social services referral system into electronic health records in Federally Qualified Health Centers, in the amount of $998,118.00. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by ONC, HHS, of the U.S. Government.”