This post originally appeared as a guest post on the Health Data Consortium blog.

More healthcare systems and hospitals are entering into shared-risk contracts with insurance companies, making them responsible for a new universe of care. Because healthcare systems are taking on the risk of their patient’s health outcome, it’s no longer enough to treat acute medical crises. Healthcare systems are rethinking care delivery to treat the whole patient, taking into account what happens beyond the four walls of the clinic.

Many refer to this strategic shift as the population health journey. (Being an avid traveler myself, that is probably my favorite healthcare jargon ever.) As the population health journey progresses, addressing patients’ psychosocial needs will become more essential to care delivery.

For example, what if a patient can’t find transportation to their follow-up appointment? Or perhaps, like 1 in 6 Americans, they are food-insecure — how can they take a medication three times a day with food? These issues are psychosocial rather than medical, but nonetheless they have an unmistakable connection to health outcomes.

Leveraging Community-Based Organizations in Care Delivery

Healthcare systems are not set up to address a patient’s psychosocial issues. However, there exist a slew of community-based organizations that can help — local networks of social services that are funded by government and philanthropic sources. Healthcare systems can leverage these existing community services to address patient needs and shape health outcomes.

Some healthcare systems already do an excellent job of maintaining community partnerships. But even for them, referring patients into community-based supports can be an ad hoc, disorganized process. Some staff know how to do it, others don’t. To provide better care at lower cost, systems that are taking on more risk need to build standardized and reliable community care pathways.

There are three key elements to establishing a community care pathway:

  1. Access to information. Staff and patients need a high-quality knowledge base about which community resources are available for different needs — from neighborhood churches, to low-cost childcare, to substance abuse treatment.
  2. Feedback. Staff and patients record which agencies work well and which don’t, and that information is available across the health system.
  3. Tracking and follow-up. Community referrals are tracked for each patient. Whenever possible, a navigator follows up with the patient to identify and remove barriers.

Referrals to Community Services are a Window into Population Health

With a community care pathway in place, the doors open to collecting data that sheds new light on gaps in community needs. By tracking referrals made to community support services, healthcare systems can measure community health, answering questions like:

  • In which zip codes has the need for food pantries risen in the past year?
  • In which neighborhoods is transit a major barrier to healthcare access?

As healthcare systems continue the journey towards population health management, these are the kinds of issues they will need to address to achieve the fabled “triple aim”: better outcomes, better patient experience, and lower cost.

Joe Flesh is the President of Purple Binder, an organization that collects, presents, and analyzes social service data to link policymakers, social service professionals, and individuals seeking help.  He showcased his innovative work at the Health Data Consortium’s Putting Health Data to Work in Our States and Communities event in Chicago late last year.