How are new solutions helping HCOs address SDoH in the community?

Join us for a discussion about different approaches to integrating SDoH into the care delivery workflow, emerging best practices, and considerations when planning your own implementation strategy. This roundtable builds off the session we hosted with executives on the care delivery side, as we look to educate the industry on the new tools available to healthcare delivery organizations and public health services following the release of our market scan report on this same subject.

Our expert panelists:

• Jody Ranck, DrPH, Senior Analyst at Chilmark Research
• Jaffer Traish, COO at Aunt Bertha
• Ed Connors, CEO at Heudia Health
• Gillian Feldmeth, Director of Value-Based Strategy and Evaluation at NowPow

High level talking points include:

• Approaches to engaging community resources.
• How does this information get back to the provider?
• Identifying the SDoH that are most relevant to your community.
• Benefits and challenges of working with patients beyond a traditional care setting.

Session Transcript:

John Moore III: [00:00:00] Here in America, our health care system is one of the most well-equipped and well funded in the entire developed world. So why do Americans so often get portrayed as receiving–in aggregate–worse care than our developed nation peers? Why do we struggle so much with making sure that all of our citizens have access to adequate care? The recent developments that have been exposed by the pandemic have revealed exactly the full extent to disparities in care and how little health equity we truly have in this country. Today, we will be talking with a number of experts that have been trying to address this issue by connecting health care provider organizations with outside systems that can provide resources in the community to help patients live happier and healthier lives. Often, these solutions are looking to address what are collectively referred to as structural and social determinants of health, which are those factors that go well beyond what happens in a care site or care setting, and actually will account for about up to 80 percent of total health care expenditures. These are factors such as military service, smoking status, income, where you live, who you live with, marital status, your credit history. All of these different things that we do outside of a care setting factor into how well we take care of ourselves and how much the outside environment is actually influencing our health.

John Moore III: [00:01:24] However, these are systems and variables that traditionally fall well outside of a provider’s responsibility. So these experts that we’re speaking with today will be discussing exactly the challenges and the success stories and some of the positive outcomes that they have experienced by working with their clients to help connect providers and patients with the outside community to really drive improved outcomes for our nation. Before we jump into things, though, let me introduce myself. My name is John Moore. I’m the Vice President of growth strategy here at Chilmark Research. And I would love it if you took a minute to subscribe and hit the little bell button. If you like our content, you’ll start receiving notifications whenever we post something new, and especially if you like the video, hit the like button and leave a comment. And someone from our team will engage with you shortly. If you noticed the time bar, there are little gaps between segments. Those are chapter headings, and if you hover over them, it’ll actually show you what the topic is that you can jump to. This will make it a lot easier for you to navigate to the specific section of this roundtable that you’re most interested in listening to.

Jody Ranck: [00:02:31] Thanks, John. So today’s webinar–and welcome to the webinar, first off. Today’s webinar is a continuation of some of the work we’ve been doing around social determinants of health that we launched early last fall, with our “Addressing Social Determinants of Health IT Solutions to Engage Community Resources” report. And in that report, we looked at some of the drivers for adoption of SDoH Solutions in the health I.T. world and some of the challenges, such as data, governance and so forth. But we ended up focusing on really highlighting what we expect this to be, an important growth area with the rise of value based care. There’s some more pressure to adopt these types of solutions that can improve outcomes and decrease utilization rates. And we’re also beginning to see more and more studies that show there’s a significant return on investment and solutions that address social determinants. And then as the year wore on, we began getting more and more data on the disparities and the burden of disease that COVID-19 represents and growing need to address these disparities. The pandemic has really shined a light on that underlying combination of social structures, institutional racism, a whole host of factors that lead to these certain patterns of the disease burden for COVID-19.

Jody Ranck: [00:04:00] One final note is that President Biden has you know, he nominated Dr. Nuñez-Smith from Yale School of Medicine to lead the social equity dimensions of his COVID task force. So we expect to do a lot more coverage of this area for some very obvious reasons that I just mentioned. So it’s a very important time right now to have this webinar and highlight some of the thought leaders and leading vendors in this space as we continue coverage. So with that, I’ll turn it over to Gillian, who will present the work that she’s doing with NowPow.

Gillian Feldmeth: [00:04:37] Fantastic. Thank you, Jody and John, for the great introduction and thanks to everyone for joining us today. And so NowPow is a women-owned technology company headquartered on Chicago’s South Side, the community where we got our start. We are a multisided community referral solution that helps people to get well, stay well managed with chronic conditions and care for others. We are grounded in science, so NowPow is a play on words for “knowledge is power”–the idea that all stakeholders can benefit from knowing more about their community, about the needs of their community and about the available assets in their community to meet those needs. As John mentioned, we’re built on the scientific research of our co-founder, Dr. Stacy Lindahl, who pioneered the idea of prescribing community to connect health care to self care with a 2012 CMMI Award. And we continue to keep science friends in mind and all that we do. Our tool includes evidence based algorithms for various health and social conditions to easily match resources to identify needs no matter of your age or stage in life. So here you can see a high level depiction of how we operationalize this going from left to right. So the first step is to identify the need that that needs to be addressed. We support identification of needs through a variety of mechanisms. This could be a validated screening tool, an ITD-10, or ZCode, or from a conversation with an individual.

Gillian Feldmeth: [00:06:10] And depending on on the user of the tool, whether it’s the individual themselves, whether it’s the care professional at a health system or a community based organization, you can imagine the workflow might vary slightly. The next step is to match identified needs to available resources in the community that may be able to help address those needs. And importantly, our taxonomy includes more than two hundred service types that really go beyond basic needs to address a wide array of chronic health and social conditions. And every resource profile in the NowPow directory is deeply indexed at the service level. For restrictions, documents required, languages spoken and other eligibility criteria to really enable successful and personalized referrals for the individual. Taking into account both what we know about the person and what we know about the community to serve up options. The next step is to share out that referral information via a variety of communication streams, whether that be email, text, friends, appending to something like the after visit summary generated in the electronic medical record. And we’ve learned it’s important to have those multiple options to meet individuals where they are and provide the right individual with the right level of information, especially I think during the pandemic we’ve seen increased discussion about broadband access and access to technology. So being able to have a variety of mechanisms to meet folks where they are.

Gillian Feldmeth: [00:07:39] For those higher risk individuals who consent to their information being shared, a closed loop referral can be made to an engaged community partner who can contact that individual, provide a service and verify the outcome of that referral. And importantly, not every resource in the directory or organization in the directory may be ready, able or willing or needed to close the loop on care via a technology tool. And every individual may not need or want that level of referral. So being able to again meet the individual and the community partner where they are is important. And then, of course, engagement. So at the end of the day, this is about supporting real people, doing this work with technology as a tool to streamline and support that process. So here, bidirectional communication between care professionals and individuals, CBOs and care professionals is key. And then, of course, analytics really underlies all that we do and the ability to generate data on each of these actions, those referral outcomes better understand our communities is essential. So with a scientist as a founder, we do take a data driven approach to all that we do. And our platform is built to collect data and share outcomes, to drive process improvements and evaluate intervention impact for all stakeholders.

Gillian Feldmeth: [00:09:00] So the ability to monitor the referral workflow and to divine the outcomes of referrals is key. For example, tracking the cycle time for the steps in the process. How long does it take to accept the referral, time to reach out to the individual, this all can help lay the foundation for understanding how partners are participating in a network. And when we think about defining what success looks like, it’s essential we learn to understand from the community partners who are engaged what success means to them. So are we expecting a social service agency to resolve a client’s food insecurity need, or are we expecting them to support the client in submitting a SNAP application, which we know is an important step in reaching food security? So really understanding and approaching the table with inclusivity in mind, with engaging diverse stakeholders, knowing that various partners have various capacity levels to to engage. One thing we’ve heard from our from our partners, health care and government and community based organizations is to really honor, maintain and strengthen that client care professional relationship and the existing health care or community based organization relationships that are already strong and really seeing technology as a tool that can characterize those relationships in a quantitative way. We can also use data to help identify maybe there are partners who are not yet at the table that could or should be engaged.

Gillian Feldmeth: [00:10:34] So by leveraging data both about what are the most commonly identified needs, where are referrals being shared to, what are the most popular or favorite resources of the folks who are day in and day out doing this work, how can we use data to bring potential organizations to the table and understand how we can again use technology to support and strengthen relationships? And on the right here, you can see a couple of visualizations; I’ll just speak briefly to the top one. The ability to generate resource availability data longitudinally can shed a lot of light on both the assets in the community as well as the potential gaps. So that food map you’re seeing on the top highlights during the early weeks, months of the COVID-19 pandemic, how food availability resources in New York City changed, both going offline, with new resources emerging and our community resources function, proactively reaches out to organizations to understand, is the food pantry offering pick up or delivery? Or are they currently unavailable? And really being able to use demand and supply data to generate insights at the community level. So finally, I’ll end on on this slide, this visualizes our approach to value and how we work to ensure that the quadruple aim not just for our health care stakeholders, but really for all stakeholders.

Gillian Feldmeth: [00:12:06] So when we think about the experience of care, again we relentlessly focused on personalized, high quality referrals. One of the worst things that can happen is when trust is eroded because an individual is given information and that information is inaccurate up to date or wholly unhelpful. And we also can think about satisfaction with care. So knowing your provider, your community sees you as a whole person, acknowledges both those barriers and opportunities to achieving health and again, being able to meet the individual where they are. Not every individual who identifies or shares that they have a need is interested in receiving a referral or intensive help at that time and being able to again surface those conversations and have a tool they’re ready to support when needed. For care team wellbeing, seamless workflows is key to this. So we constantly hear the desire to have fewer clicks, automated suggestions and being able to really embed any type of tool in an existing system. So whether that be the EMR or if you’re a CVO, your case management system, or for research partners, tools like Redcap, being able to complement existing workflows with this piece of the puzzle to really provide a one stop shop to be able to do this work. And when we think about the right information for the right team member, maybe if I’m a clinician, I would like to stay in the loop on what referrals or needs have been identified.

Gillian Feldmeth: [00:13:41] But maybe I’m not in a tool like this each and every day, sharing out referrals. So being able to, again, provide that right sized fit for the information. In terms of population health, whether you’re a high risk patient with many needs, an individual with a chronic health condition in need of management support, or an individual who is already well and looking to maintain that status or maybe looking to support someone, someone that they love, that’s important to be able to meet all of those different population types. And then when we think about cost and I think one thing that we’ve learned from our partners in terms of evaluating intervention success is leveraging common tools like logic models to really be clear about what is the process-level outcome, short term, longer term outcome, and knowing that it could take years to realize some of the return on investment that we know to be there. But it is important for all stakeholders to be included in every step of the way. Celebrate successes. Maybe folks are coming to the table to first understand the needs of their community and then work to bring the right parties to the table to address those needs. But having an objective, having that guiding light in sight and working every day to to measure success along the way is is essential for all parties.

Jody Ranck: [00:15:01] Great, well, thank you. Thank you, Gillian. And so now Ed is going to tell us about his work with Heudia.

Ed Connors: [00:15:08] Yes, thank you very much today, Jody, I appreciate the opportunity to speak out and give another perspective on social determinants of health. Heudia has a platform access we carry that allows anybody to do what we would all do for a friend, family member or loved one experiencing a health or social crisis: figure out what your needs are, determine what are the right set of providers and care organizations that match those needs, that help people overcome. And we’re passed through barriers to care to better engage and have a healthier more self-sustainable life. So my background and experience coming into this is that of an engineer, of an educator who became interested in addressing the needs of the vulnerable populations out of a chance encounter with an obese middle school student. We quickly realized that this problem couldn’t be solved in a K-8 classroom. You needed to get a larger number of community-based organizations working better together to really address the health disparities and focus on education, education and experience and activities at the community level that were really based upon behavioral economics. Our phase one platform was deployed not to address the problem of childhood obesity, but to really improve access to care for the low-income Hispanic individuals. Right in the additional couple target communities that we were implementing into. So that was really focused on reducing their dependency on emergency department resources where they were going for primary care.

Ed Connors: [00:17:02] With this work experience, we really look more towards what are the root cause problems that were impacting on the individual’s care journey. So with a lot of cases, rather than just looking at it as a brick and mortar problem around food or housing, we became a little bit more–a lot more–focused on what I would call the intangible barriers to care: knowledge, fear, distrust, income, insurance, shame and stigma, as a reason why people weren’t getting what they needed. We have found that when we can address knowledge barriers in the community, we can rapidly increase the rate of referral between a primary care center and a behavioral health care provider. Or with a maternal health care provider like a Healthy Start program that we were working with in rural South Carolina, for example, where by applying and overcoming those knowledge barriers and better engaging community organizations, we were able to increase rate of referral between some of the contact points within that community, those community based care providers, by 90 percent in 90 days.

Ed Connors: [00:18:23] So when you think about how we really look at this problem, we actually see it as a double sided problem. Where on one side, it’s low-income individuals that depend on resources that are inconvenient and accessible don’t necessarily address their barriers to care. And that’s a major component. That’s where a lot of the work in the SDoH space has been done. But on the flip side, the organizations that they depend on most are on the lower side of the spectrum and these community based organizations need better intelligence and networking tools so that they can connect people with services. And just like the individuals themselves have knowledge barriers, so do these organizations. And it really is the empowerment at what I would say one level above the individual themselves, where if you can intervene and better engage with those community based organizations and really work hard to improve inner organizational collaboration and coordination, the effectiveness of the cool kids that are being placed in the SDoH space and are being launched by organizations and companies like Heudia, NowPow and Aunt Bertha become much more effective. I look at this again from a perspective of–what’s the holistic approach? How can we collaborate together not just as individual companies or companies working with community based organizations, but as solutions providers for the SDoH space overall. So really, when you think about it, it comes back to this ability to engage community organizations as to really how do you educate and how do you engage? How do you interact? The more frequent your interaction and the more you can really engage, the more you can shift and inspire others to address those barriers to care, gaps of care, at a community level.

Ed Connors: [00:20:29] And that’s really what Heudia’s technology stack and data focus has been with access to care. How can you empower grassroots organizations to do what they do on a day to day basis to improve access to care and really address income inequality? Because at the fundamental level, the single problem addressing or impacting on SDoH is really poverty. So how do you relieve that burden of poverty and realign organization? So not only are we looking as a resource provider and as a community engagement platform looking at housing and food, what about employment and education as being key fundamental barriers or needs? You have to be able to address.

Ed Connors: [00:21:22] So when you really think about one of the best moments in the history of of AccessMeCare and Heudia, it was with the project we were we were launching. We’d done our community engagement work, our client had asked us to go out to and help out at a Head Start program that was doing a community health wellness fair for low income children in the community. And one of the the community care navigators that we had sent out to help them out was interacting with a woman. And I’ll just call her Joan for today’s presentation. And one of the first seventy five people passed by. And what she said was– when asked, how can we help? Are there any health or social needs>–the response we got was, oh yeah, my six year old grandson was left out of first grade. He wasn’t able to see the board. We don’t know where to go to get low cost glasses. A perfect use case for access to care. And then she said something that was incredibly important. 60 seconds later, she came back, says, “I have a cancer on my nose. Where do I go? What do I do?” And at that point, you know, we can have a much more effective engagement. The layperson navigator was able to recognize that she had four barriers. She had an income barrier because she was laid off. She had an insurance barrier because she was laid off and failed to sign up for Medicaid or Medicare that would have been an option to her. When asked if she knew about the new cancer center that was just two miles away, she had no knowledge of that. And of course, they had social service workers and financial counselors who could have helped her around the economic issue. But really, most importantly, she had fear. She needed to engage a little bit about the boy before she really felt comfortable addressing her needs, even though they were much more significant.

Ed Connors: [00:23:31] And overall, to me, that’s the real value of the platforms that we’re putting out into the field to address social determinants, because at the end of the day, the more people who are empowered to have these types of conversations–it’s critically important. And then the other really interesting nuance about this encounter was two tables to the left was the Medicaid-managed care organization and two tables to the right was the hospital. But this conversation played out just because of the empowerment that was able to happen through the use of our platform AccessMeCare. Right. And that’s just to say that the more conversations we can have around social determinants and the more we can engage with people and with the ability to address scarce economic resources within communities. And we’ve proved that the better chance we have of really being able to make a systemic impact on on the continuum of care. So I come back to the fundamental premise: knowledge empowers all. So the whole goal of what we’re doing here, Heudia with AccessMeCare, is really to help motivate people to become more active participants, increase understanding before and after the point of care. So thank you today for allowing me to present.

Jody Ranck: [00:25:02] Thank you, Ed. Now we’re going to have Jaffer to speak about Aunt Bertha’s work.

Jaffer Traish: [00:25:08] Thanks, everyone, appreciate it. Aunt Bertha’s mission is very similar to that of NowPow, I think we’re quite aligned. And even though we do things a little differently sometimes I think we’re very much in this for the right reasons and for the community. Our mission is to connect all people in need and the programs that serve them with dignity and ease. We were born 10 years ago. Aaron Gray, the founder, became the legal guardian of his mom, who developed a rare brain disease and, long story short, created this mission that has been the same for that time period. And it’s been an exciting journey working in communities across the country for our work. Part of today’s ask of us or focus was to discuss what we’ve learned, what we’ve observed, not just during the pandemic, but in this work across the country. And so instead of talking about the platform and close up referrals and so forth, I wanted to share a little bit about what we’ve seen. On the top left, you’ll notice that we’re looking across the time period right about when the pandemic started, that yellow block. And you’ll notice across the entire country, we saw about fifty thousand people per week before the pandemic, doing program investigations, doing searches, doing connections, finding program resources through the Aunt Bertha network. Shortly after the first week of March, it doubled. We saw a hundred thousand people per week looking for resources.

Jaffer Traish: [00:26:33] Unemployment checks went out a few weeks later. There was a little bit of relief. You see a little bit of a dip there into the seventy five thousand a week mark in May. But then something interesting happened. From July to October and forward, the numbers steadily increased and that is representative of the 40 million people that became unemployed, checks that ran out, people who may have lost their homes. And it’s sobering. But now we see close to one hundred and fifty thousand people per week looking for resources across the country, nationwide and growing. On the right hand side, we just zoom in to Texas and the theme in Texas is similar to the nationwide chart where pre-pandemic, it was about eight thousand or so people a week. Now we’re hovering around the fifteen to twenty thousand mark, looking into February, for the number of people per week. And importantly for our customers, our partners, many organizations that do community engagement across the state, we’re able to see exactly where people are going. So we picked up the phone and called Echo, one of the four hundred or so homelessness coordinated care organizations across the country. We saw almost ten thousand people going to Echo to get additional navigation for housing. And so we partnered with them to continue to build out integration and workflows, ways to help the people going to them get the help they need.

Jaffer Traish: [00:27:58] So this data is very powerful, not just for our work with with our customers in the community, but to inform policy–don’t have a slide for it. But in Texas, dentistry and dental services was the third most searched term in Texas. Well, probably no surprise to many of you on the phone–dentistry is not covered by Medicaid in Texas. And so helping identify some of those needs helps inform state policy as well. We also think that taking a strong network approach really supports the community as well, and by all means, health care is one door, one entry point into social resources and connections, and we should support health care. But what about the person-driven self navigation of referrals where I want to help my family from the privacy of my own home? What about the small programs that are the mom and pop shops that aren’t going to engage in a value based contract with health care? What about the small philanthropy organization that provides financial support for those with cancer treatment? So there are networks out there that take a closed approach. It’s part of a value based contract. It’s 10 or 20 non-profits. That’s a good thing, but it’s a closed network. Why can’t we think bigger and have both an open network available for communities and also focused, prioritized networks included that have covered benefits, value added benefits and more? And so we’re excited that are our customers and regions are taking advantage of this open and focused approach to do broader population work and not just address chronic diseases where sometimes it’s too late.

Jaffer Traish: [00:29:38] Another core principle, and this is something that I’m very excited that some of the other vendors on the line have chatted with us about, is this concept of not forcing non-profits into just using one tool that the government mandated or said you have to use that really puts nonprofits in a tough spot. So a key philosophy here is, can we support interoperability of social care referrals, and can we give nonprofits the choice to protect their mission, their anonymity, of how they help people, and how they choose to respond to referrals? And I think one of the previous speakers made this point as well. We can support the nonprofits by giving them choice, and how they control how they share their outcomes, and how they protect information that they collect and still serve people and communities. And that’s the concept of CBO choice. Another topic that I think is being hotly debated today, not just by HIPAA and some of the proposed changes that we’ve seen out there, but more importantly, we don’t have a consumer-directed privacy framework.

Jaffer Traish: [00:30:41] And this is something that the ONC and others have talked about more recently. From the Aunt Bertha perspective, we believe that there should be a permission-based access to social care information, a peripheral consent process. And that’s different from what is an all-in consent that benefits industry or benefits financial reward for investors. And what I mean by that is; if you’re a part of a family in rural Pennsylvania and you sign up to get some help from your health care system to navigate on behalf of you for social care, well, if they’re part of a network of 300 different organizations, any person in that network can look up your history or your child’s history. Maybe seeing things like substance abuse issues or perhaps that you had to call that domestic violence hotline. Is that appropriate? Well, that’s up for debate. But our belief is that that consumer, that person should be in control of who sees that private, self-navigated history. And it should be a permission-based approach. Not anyone can look up your social care history approach, which can harm not just through stigma, but through potentially reducing government benefits and other issues, when this information is open to all to see. So those are a few key principles that I wanted to call out in our learnings in building trust with communities.

John Moore III: [00:32:03] Thank you, Jaffer. So Jody, if you want to start moderating the discussion?

Jody Ranck: [00:32:08] So I’ll begin with a question of a broader kind of policy question across all the panelists and what trends in social care they’re seeing driven by state policies or shifts in state policies to address these health disparities and what patterns and trends that you’re seeing in different states. If you don’t have any insights on the states then perhaps what you think going forward at the federal level with the new administration kind of looking at that policy drive or so. Since we haven’t heard from Gillian for a while, do you have any thoughts, Gillian? To begin with you and we’ll go down through the line.

Gillian Feldmeth: [00:32:50] Sure. So I think at a high level, we are a diverse nation, so certainly a lot of this is about meeting partners where they are. And oftentimes we see a high degree of variation in terms of sophistication, number and type of value-based care arrangements that may be live in certain geographies and being able to be flexible and sort of meet the partner where they are, in terms of where they need to start. I think from a national perspective, I think the health equity task force is fantastic. It is refreshing and relieving to have that sort of communication coming from the highest levels of leadership. But I think that also most of the folks that we work with who have been in this for years have already been been doing this work. And so I think acknowledging that various partners have lessons learned to add, as the pandemic, of course, exacerbated and shed light on on some of these terrible disparities that we see. But for most folks that we work with, this is not new information. So I think there is an increased appetite, regardless of state, regardless of location, to ensure that that all stakeholders are brought to the table to really solution together. And that’s one thing that I think is fantastic about being able to be on a panel like this when in some lights we could be considered competitors. But in order to to make progress, regardless of geography or regardless of partner, it’s a fantastic deal to come to the table and talk about what we’re saying and and how we can all support together.

Jody Ranck: [00:34:34] Ed or Jaffer, do you have any thoughts as well?

Ed Connors: [00:34:39] Well, my thought on the relative to value-based care is that I think it’s incredibly important to to be able to look at what are some of the really strong performance measures. Sometimes it’s hard to prove a negative. So if you’re out there working and of course, if you’re doing the referral component, you can you could start to see what’s happening. But the question is what happens outside? Because we’re talking about population health, a large ecosystem, and sometimes it’s hard to associate. You can do some really great work. And how do you capture that? How do you really correlate that and associate that with some of the improvements, kind of like the butterfly effect. And how do you how do you figure out what’s going on in those communities to really assure that you can provide that care, the value-based evaluation that’s really needed?

Jody Ranck: [00:35:36] Jaffer, any thoughts?

Jaffer Traish: [00:35:38] Yeah, yeah, absolutely. There’s so much going on in the policy world, there’s so many acts being proposed right now. There’s debates, as I mentioned, on privacy and the social care space. But some of our customers are really getting to the brass tacks of the work. And in Massachusetts–where we work with Mass General, where we work with Boston Medical Center, 15 other organizations–they actually adopted the Mass Health accountable care organization, flexible services model. And what’s really unique about this approach is they have funding from Mass Health to pay for health-related nutrition and housing supports for certain members. And they have a focused network that’s actually getting reimbursed for providing these social care goods. And they can begin to do some of this analysis we’re talking about, like marrying up their chronic diabetes registry participants to those that are receiving medically tailored meals and nutrition counseling and so forth, and start to do some of this study to identify where we continue to focus our efforts. So there’s this opportunity to bring the data that we see across the network and help guide the efficacy of some of these demonstration projects, whether they be a flex services type project, an ACO project or an 1115 waiver that’s supporting reimbursement. And so there’s a lot of demonstrations going on. I think we need to continue to see more of them. I’m weary of us trying to prove an ROI for an industry in doing this work too soon. I think we need to see more investment in actual staffing of care coordinators and navigators and operationalizing this work by our partners in health care before we can expect that there’s some sort of bigger reward. So I think there’s a chicken and the egg thing happening sometimes in this space.

Jody Ranck: [00:37:23] That makes perfect sense. And I know it’s an ongoing challenge that as an industry, we need to think about when it comes to these social determinants, that you really do have to take a longer view and have more patient capital to invest in the resources to really get the job done. And the next line of questioning–we have a couple of questions I’m going to try to weave through here that get more in there, more granular questions that get into the mechanics of how you folks do what you do. And the first issue is, how do you address the interoperability challenge across EHRs with your solutions? So who would like to go first and we’ll go down the line. But then after that, the follow-on question is going to be for your end users and how they access the systems. And what do you do about disparities in access to technologies to access these types of tools? So first, the interoperability question across EHRs. So who would like to go first on that one?

Jaffer Traish: [00:38:42] So I think there’s two two main pieces here. The first is how do we make sure that vendors like us are integrating not only the navigation, but also the content about available programs into the workflows of those in the community. And that means integrating into EHRs like Epic and Cerner into their own platforms. That means integrating into Salesforce. That means bringing the network to the users so that it can be adopted successfully. But then there’s the question of interoperating referrals, referral history and assessment information into other places where it’s needed for the community. And that may be an HIE. That may be a data aggregation warehouse where UT or a university like Stanford is doing more research.

Jaffer Traish: [00:39:28] And so today we’re missing US CDI based standards that support this interoperability of social care information. And there are some good proposals out there. But we’re also missing some standards for what defines a social care referral. What defines a social care assessment and how it’s codified against ICD codes or others. And the Gravity project is starting to do some of this work, and it’s a great start. And I think folks like NowPow and us and others have written white papers about interoperability and what we think is some of those core data elements can be. But we’re really in infancy and having a true standard out there to support exchange of this information. But I would argue most of us are on board, but that’s the right thing to do.

Jody Ranck: [00:40:11] Any thoughts?

Ed Connors: [00:40:14] Yeah, Jody, I kind of take this a little bit of a different direction first and say that for Heudia, it’s not so much about moving patient data. It’s about moving people and patients to the right center of care. You don’t need to know a lot about a person’s health information to get them to the food bank and other things. So minimal touch, minimum captured data, really not to suggest that having more data isn’t better to help align somebody with the resources they need. But at the end of the day, there are so many millions of people out there that need care. And interoperability is not a technical challenge. It’s a human challenge. It’s about how can you think about, on one hand, interoperability? We can do that among ourselves in the social space really well. If we have a professional and personal commitment to bring our referral platforms together in a way that allows us to establish the right protocols and the right processes and the right methods of exchange, that’s easily done. But if, on the other hand, you’ve got EMR companies and hospitals that don’t want to exchange information and really make that happen, then the challenge becomes more of a personality and policy than it is really about technical infrastructure.

Jody Ranck: [00:41:38] Gillian, any thoughts?

Gillian Feldmeth: [00:41:40] Yeah, I agree with both panelists. I would also add, I think we’re starting to see an increased interest and emphasis on the role of community-based organizations and what integration can and should look like for those organizations, and not just focusing on on the major hospital systems. So I think as Jaffer suggested, I think there’s more that that can be done there to really understand and make sure we’re including the community organizations. And their capacity is simply a single sign-on or same sign-on technology projects going to help them to engage a little bit deeper. What does interoperability mean to those community organizations? What does integration mean to them? And really thinking also beyond the technology and just integrating into workflows, taking the time to understand how does a community organization currently do this work and how can technology support that and not be a replacement to the real people doing the day to day work if there’s an Excel spreadsheet? Well, maybe the new technology is going to be the better solution, but sometimes not, so being able to sort of be honest and meet folks where they are.

Ed Connors: [00:42:51] And I would say that Gillian, that’s a really great point. And it bears out the fact that one of the big challenges in the SDoH space is the dynamic range between big health care systems that are trying to do the work and do it well. But on the other hand, you’re working with really grassroots community based organizations and their technology and the sophistication is, you know, light years apart. So I enjoy the idea of starting bottom-up and working that way. But we’re the folks in the middle that need to pull it all together for the stakeholders.

Jody Ranck: [00:43:28] But to build on that point that we have a question about, how do we ensure quality in the services provided by community-based organizations? How are you guys thinking about that? And, you know, someone’s also asked about standards for CBOs, the data standards for CBOs and assessing them. Where are you folks in your thinking about that as well?

Ed Connors: [00:43:57] Well, as a director of quality assurance for aerospace and defense companies for about 15 years, Jody, I look at it as almost like supply chain management, where you assess the interaction that’s occurring through the ecosystem. So when somebody is engaging with a partner, you can do a survey on both the provider side and the patient side and start to collect that information and build it or continual improvement. But at the end of the day, it’s a supply chain management challenge.

Jody Ranck: [00:44:33] Gillian, do you have any thoughts?

Gillian Feldmeth: [00:44:35] From the NowPow perspective, we put a lot of effort and emphasis on ensuring the information that community organizations–that we’re reflecting about organizations– is accurate and up to date. For us, that means employing an in-house team of individuals who are reaching out, contacting those organizations, also allowing organizations to update their info and let us know if something’s wrong. When we think also about the users who are interacting with the tool each and every day, oftentimes it’s that social worker or that community health worker to CBO who is the primary source of truth for maybe the intake specialist at CBO one, two, three, recently left. So the ability to have multiple channels where that information can be delivered and ultimately takes the work off of the care professional, off of the person sharing the referral, to have to do that double-checking, to have to make that call before sharing the information with the patient and allowing another organization, whether that be NowPow or someone else to do that updating process, is important. But I would also say, in some communities there are already great sources of truth for what those resources are. So the ability to work with those organizations, whether that’s the 211 or another trusted organization in the community, is essential. And I think more can be done in terms of interoperability between those existing resource directories and other tools. I think none of us want to waste effort on updating the same information. But there’s a high degree of variation. Here in Chicago we don’t have a 211. It’s just doesn’t exist, whereas some other communities, that is a great source of truth. So what does it look like to to engage with those partners?

Jody Ranck: [00:46:25] So, you know, we’ve spoken about some of the challenges along the way and we all recognize we’re dealing with a lot of really sticky structural issues in our society. So I’m sure you get asked this question from investors and funders–how are you thinking about scaling your organization and your approaches to have wider impact? Where’s your thinking at on the issue of scaling up and when do you decide you’ve had enough impact and you know, you have the platform that can scale. Where’s you’re thinking? We’ll just go right down through the line. Who wants to start?

Jaffer Traish: [00:47:06] I’ll start on that one. I think we’re in infancy in this space. It’s this country isn’t like Finland and some others that social care has been a part of their ecosystem for so long. Actually, many of you probably know Epic actually started their social care module overseas for the last three years. So we’re learning. But I think number one– philanthropy in this country, Rockefeller Foundation, Robin Hood, Gates, so many others are craving information and data about what communities need to succeed. George Halvorson from Kaiser was talking about how do we get books in every Medicaid families home to start at the educational level. There’s so much we can do and think about. And many of us, I think, probably agree that collaboration beats competition every day of the week. So comments from Tonya and others that say how do we remove some of these competitive barriers and create a better playing field for the community where we’re competing on product and not necessarily other things that slow us down is also important. But I think the concept of looking at payers in this country who are starting to really align a lot around social influencers of health and wellness, they have coffers now over the last year of millions of dollars, and they’re starting to do creative things like pay for car seats, for families, like pay for meals for a new mom for the first three months, like pay for pest control to keep people in their home. These are the creative ideas that I think are going to define the next few years where we’re solving someone’s need quickly, as opposed to waiting for a referral from a nonprofit that may not have the capacity. So I think we’re going to start to see layers of networks created around the country.

Ed Connors: [00:48:43] I think when I think about the challenge is to scale is, you know, it is somewhat, at the bottom-up level, about community building. And there’s nothing but time you can do. I think from a technology standpoint, you know, it’s it’s very similar to probably the infancy of email. You’ve got to be able to get everybody on the same platform, be able to have these open networks where we can all contribute community data to so that we can focus on our clients, target population and working on scaling that. I don’t think–again, the technology is not the challenge to scaling. It’s how you can engage more people more meaningfully in the least amount of space. And that’s where the scaling challenge is actually.

Gillian Feldmeth: [00:49:38] I’ll just end on a note of optimism. I think that five years ago, maybe even four years ago, three years ago, we would have to enter conversations and define what are the social determinants of health, what are social risk factors. We are past that. And so I think the ability for all of us to to scale our solutions to help communities either elevate the work that they’re doing, or support communities in embarking on this for the first time, is just going to be increasingly easier because we are now sort of all on the same page for the fact that this that this work is important. So for that, I’m really optimistic. And I notice there’s a few questions in the chat that we weren’t able to get to. So I’m wondering, John and Jody, if there would be an opportunity to provide responses to some of the folks that we didn’t we didn’t quite get to today?

Jody Ranck: [00:50:29] John, if you put up that screen with people’s email addresses,  they can reach out to us that way. And in the meantime, I just want to thank all of our panelists for sharing your very rich experience with us on this today. This has been very insightful. Thank you.