Leaders at UVA Health Use HIT to Create a Platform to Improve Communications with Community Groups

June 10, 2020
Leaders at the University of Virginia Health System have been leveraging health IT to help them build stronger communications and connections with community-based organizations, as they address SDOH

The focus on the social determinants of health (SDOH) and their impact on the health of covered populations, has become a larger and larger element in the strategic planning of the leaders of patient care organizations nationwide. It is a complex area, both strategically and practically; but more and more hospitals and health systems are taking it on directly.

Among those is the University of Virginia Health System, an integrated health system centered around the 612-bed UVA Medical Center in Charlottesville. There, in 2018, UVA Health senior leaders made the strategic decision to help patients beyond the hospital walls by partnering with community organizations. UVA Health leaders were guided by their understanding of the direct impact relationship between a number of social determinants of health factors and lengths of stay (LOS) for its patients. As research has consistently found, only 20 percent of an individual’s overall health status is related to clinical health care, while the remaining 80 percent is shaped by socioeconomic factors, their physical environment, and their health behaviors. Having access to healthy foods, safe and stable housing, reliable transportation and a well-paying job leads to increased well-being.

So at the outset of this initiative, UVA Health leaders selected a technology-based referral network from the Dallas-based Pieces Technology, which was founded by Ruben Amarasingham, M.D., a Parkland Health & Hospital System medical director who created Pieces Tech in 2016 in order to develop end-to-end monitoring, prediction, documentation & discovery software for health systems and community based organizations.

With the help of the Pieces Technology folks, UVA Health leaders launched a community group that leveraged technology to improve communication and solve the shared challenge of having up-to-date information about resources, referral processes and eligibility criteria. Their comprehensive strategy was successful because it focused on bringing value to all of the organizations in the community; not just the needs of the health system – and most importantly, on patients in need.

The UVA Health senior leaders focused on four key goals: seamlessly following the patient across the care journey; making “place-based” investments and reinforce community assets; adapting  technology to “meet us where we are”; and creating a community platform that helps to address and respond to issues beyond SDOH.

Recently, Amy Salerno, M.D. MHS, UVA Health’s director of community health and well-being, and Dr. Amarasingham of Pieces Technology, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland, regarding UVA Health’s ongoing initiative. Below are excerpts from that interview.

Tell me about the origins of this initiative?

Amy Salerno, M.D.: I was brought into UVA in order to be the director of community health and well-being, which was a new office, at UVA, just under three years ago. Specifically, our leadership at that time really felt we needed a renewed and reinvigorated partnership with our community, in order to pursue overall health in our community, not just among our patients, and to be data-driven in that. So one aspect of the work is focused on the social determinants of health, and that’s been the major element. And as part of that, we looked at where we were as a health system, and did a lot of listening in our community, in order to hear about what the needs were, knowing that we wanted to serve more than just our patients, but rather to have a bigger impact on our whole community. And we knew that we didn’t have a complete system for screening for social determinants. And then our community-based resource directories and referral lists—there were something like 30 of them. And everyone had their own rolodex. So, thinking about what tools could help us deliver, we found Pieces when we were at an audio conference. And we really felt excited about it, because it’s a tool that does a few really critical things for us.

First, it serves more than just our patients. It’s a system and a platform that can serve the entire community; so if someone shows up at a homelessness service organization, they can be connected through Pieces, even if they’ve never been a patient. And it can act as a case management system, as it tracks data. And could potentially connect us to grants.

And the Predict side of Pieces uses natural language processing. As a doctor, I write the social context of my patients in my history and physical documentation; and it’s in my notes, and Pieces Predict can pull out that information; and allows us to track SDOH data, and allows us to interact faster with those patients. And it allows us to track data and outcomes across the continuum of care. Community health needs assessment is one thing; but where can we invest more in our community, to achieve a broader health impact? Those were things that this tool has allowed us to think through.

What does this look like, day to day, now?

Because we engaged our community partners in shared decision-making, we’ve had a long road into implementation. Various components have been implemented at different moments recently. Pieces divides it up in different ways, such as Predict and Community Implementation. The community implementation—that’s been ongoing, and several community partners signed contracts about four months ago, to do community implementations, and they can use it as a case management platform and can accept or do referrals. We started using it as a case management platform ourselves about a month ago. We accept anyone to speak with a physician or community-based organization, for free, and that went live about a month ago. We purchased ReLOS, a module for reduction in length of stay. We were supposed to pilot it on March 30, but the coronavirus shifted our work, so we’re just now doing that pilot. Our case managers and heads of hospitals all have log-ins now, just in the past few weeks.

The data analysis—starting a month ago, Pieces has been producing reports for us around race, ethnicity, and social need. So the social need reports have been available for about two months now. So it’s about giving us the data so that we know how to change our workflows. If an issue surfaces, it can lead to an automatic referral to social work.

So this multi-channel platform helps you to analyze data and trigger referrals and interventions?

Ruben Amarasingham, M.D.: We want to use NLP to identify information and take action. The non-clinical actions will be reducing lengths of stay, for example. A big portion of this will be around social determinants, so it will involve making sure the right pathways can be created. And then there’s the ability to make the referral to the right community organization. And then, per the community organizations themselves, we’re providing them a platform for them to use, for them to manage their clients; that provides a more seamless flow of information among the parties. And then the last piece involves tying it all together, to see whether we had an impact on them both clinically and terms of SODH.

What have been the biggest challenges involved, and how have you overcome them?

Salerno: The slowness of the process is sometimes necessary in order to get internal and external alignment and buy-in, around things like length-of-stay initiatives, for example. The hospital, a lot of times, the speed at which the hospital would like to move is faster than what the community is comfortable with; so balancing community input with hospital executive decision-making, has been one of the hardest tightropes to walk. Community leaders can’t feel bullied, and can’t be rushed, because the robustness of the network won’t be there.

The challenges have primarily not been technological, then, correct?

That’s correct. It took longer than we had expected to build out the technology at UVA, but it’s all moved forward. And I’ve sat in on all the HIT troubleshooting calls, and there have been little snafus here and there, but they’ve worked through all of them quickly. It’s really been around competing priorities internally and mistrust internally. And Pieces has really been able t meet our community where we are, and to think through interoperability and integration with other systems. Just as inside HIT, HER integration is important, there is a Homeless Management Information System that’s a federally mandated program that all service providers are required to report through, and there are multiple versions, but all called “HMIS.” And there are technology platforms that function as HMISes in every community. And we also have a job matching service that connects people with jobs and helps to break down barriers around housing, transportation, food, and clothing for interviews. And the social service agencies had a platform for that. So we had to work with the existing systems already being used in the community. Pieces was the link that helped crate an interoperable system with Network to Work, that system. That’s a local platform, but most communities have some sort of referral platform; some communities have 211.

So Pieces has helped create a level of interoperability?

There is a plan to create interoperability, but we’ve spent a lot of time working through this. And this is something that will have to happen in other communities as well.

Amarasingham: I think that this is really the next frontier in interoperability, as we start to see the healthcare sector interacting with other systems—healthcare to housing, healthcare to schools, healthcare to criminal justice—all those involve new types of interoperability. And our commitment here at Pieces is to provide that connectivity, as well as massive translation efforts to connect very different types of systems with very different requirements. So this is an important new horizon for the healthcare technology sector.

What would your advice be to colleagues at other health systems who are moving forward on this journey?

Salerno: From a how do you make this work and make it effective standpoint, it has to align with both your internal goals and direction, and external objectives. So for us, it connected to our work around length of stay. And externally, you’ll fail if you don’t engage community leaders early on, or make them feel excluded. If somebody doesn’t have housing and you haven’t already engaged the homelessness service providers and just start inundating them with massive referrals, they’ll be overwhelmed. So there’s a lot of relationship building and trust building. You have to reach out and engage early and to lean on the expertise of those community service providers. The homelessness service providers have been focusing on that area for years. So you have to treat them as the experts and engage them as such.

Amarasingham: One thing I’ve observed at UVA is the importance of significant leadership from leaders like Dr. Salerno. These are complicated, multi-stream efforts that require a great deal of outreach to and engagement with the community, and translators like Dr. Salerno. The technology actually is a secondary concern to the organizational transformation and community-wide efforts that really require special leadership. And it’s rare to find clinical leaders who have those dual lenses. But if a health system is interested in this area, that level of leadership is a critical differentiating factor.

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