There is an increased recognition among healthcare payers and providers of the impact of social determinants of health (e.g., social needs, such as nutrition, transportation, and housing) on health outcomes and costs. As such, there is an opportunity to create partnerships between healthcare and community service providers to fully address medical (i.e., clinical) and non-medical (i.e., social) needs. However, our current healthcare delivery and community service systems are fragmented and siloed. Though providers from both systems may serve the same senior patient, often there is a lack of communication and no single care plan. The result is uncoordinated, inefficient care for senior patients with complex needs.
As part of a multi-year collaborative research effort, the Gary and Mary West Health Institute (WHI), the University of California, Irvine SeniorHealth Center (SHC), and SeniorServ, the largest community-based organization (CBO), developed and are currently testing a care coordination model to help bridge clinical and community settings in an effort to provide patient-centered care and enable seniors to maintain their functional independence. The ‘360° Caregiving Solution’ is an innovative, technology-enabled care coordination model to identify and address the full range of needs among senior patients, including the social determinants of health. The primary aim is to transform the patient experience from disjointed clinical and community services to a comprehensive treatment plan that considers all the needs of the patient, coordinates their care and alters their care plan based on their current needs or change in clinical condition
The study consists of three phases. In Phase 1, a formative evaluation was conducted at the SHC and SeniorServ to understand staff perspectives, current processes and opportunities to identify and address seniors’ unmet social needs. Findings informed Phase 2 efforts, which included the development of a 12-item senior-specific social needs screener that assesses if seniors are at-risk of an unmet need across 7 social determinants of health domains: (1) social connections or isolation, (2) daily living and mobility, (3) caregiver assistance, (4) food and nutrition, (5) housing, (6) finances, and (7) transportation. Phase 1 findings were also used to help develop and test new workflows to identify and address social needs within the SHC, as well as a customized electronic care coordination platform (CareScope) with research, clinical and community-based partner input. The electronic platform is designed to streamline service referrals and facilitate ongoing information sharing across clinical and community service settings. Extensive user testing was conducted during Phase 2 to ensure critical information could be easily collected and communicated among clinical and community providers involved in the care and support of a patient. Phase 3, which is in progress, implemented the 360° Caregiving Solution pilot. A community-based social worker (i.e., care navigator) is embedded within the SHC clinical care team and is using the electronic care coordination platform to provide comprehensive service navigation, including screening for unmet social needs, assessing service needs and connecting patients with the most appropriate community supports to address identified needs. The effectiveness of the 360° Caregiving Solution intervention will be assessed by comparing baseline self-reported patient outcomes and utilization data from the EHR with follow-up data at 3-months post.
