Informaticians Working on e-Referrals to Community-Based Organizations

As health systems move into the world of addressing social needs or increasing connections with social service agencies, informaticians are researching how to use data to predict which patients could benefit from referrals to community-based organizations as well as how to send closed-loop e-referrals from EHRs that contain a limited amount of relevant patient data.

During a Feb. 19 Systems for Action webinar, Joshua R. Vest, Ph.D., M.P.H., director of the Center for Health Policy in the School of Public Health at the Indiana University Purdue University Indianapolis, described research work his organization is doing to implement machine-learning-based risk stratification to identify patients in need of what are called “wraparound” services such as housing, transportation and food assistance.

Vest began by noting that among the challenges facing healthcare organizations, there are increasing demands for accountability and the assumption of risk and a recognition that social factors related to poverty complicate care delivery, foster health disparities, and are important to health status. “The current medical care system is not designed to address these issues,” he added. “It is organized to get people into treatment and get them out, and is not conducive to a long-term, high-touch approach that social issues need. When a patient has a social need, primary care doctors are not the folks tasked with dealing with that need; social workers are trained and their work is structured to address those.”