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A Social Determinants Program Case Study

Pilot projects are popping up all over the U.S. to address what some call Whole Person Care. Essentially, we are talking about a physician driven but community wide approach for addressing a patient’s medical, behavioral and social needs.

Northern Physicians Organization has implemented such a program using Iguana to support its case management platform shared by physicians and public health departments. Read our case study on how NPO helped its community build its social determinants of health program.  

The challenges NPO is addressing through information technology mirrors programs like it across the country. Effective and timely data exchange is a key component of making programs like these work. 

For example, the state of California launched 25 Whole Person Care Pilot Projects in 2017, and an April 2019 report reviewing the successes and challenges of the projects found that data sharing was the second most challenging issue in implementation, only behind meeting participants’ housing needs. 

While not every issue related to data sharing was technical — the study cites several legal and cultural barriers to data exchange — the technical requirements have common themes with NPO’s implementation:

  • Gathering data across disparate information systems. In some cases, that can include data from non-medical information systems used by social services agencies.
  • Building a platform that provides patient case information to all stakeholders and tracks the progress of care coordination.
  • Creating visibility across stakeholders of patient readmissions.
  • Aggregating data to analyze and report on effectiveness of care coordination efforts.
  • Making the process of documentation into the care coordination platform efficient for front-line workers and reduce duplicative effort and the need to manually aggregate data from multiple sources.

These are the challenges NPO has successfully addressed.  To learn more about the Northern Physicians Organization’s story, you can download your free case study here!

Nov 28, 2019iNTERFACEWARE
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Building a Blueprint for a Social Determinants ProgramHow Connecticut Children’s Medical Center Streamlined Management of Patient Records and Maximized Operational Efficiencies
November 28, 2019 Case Study, Tips and Tricks, value-based care
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