*This article is written by CBCS Founder, Enrique Enguidanos, and is a re-post from Becker’s Hospital Review that ran on April 29, 2020.

Earlier this year, communities around the world engaged in a collective movement called “social distancing”. Schools and offices shut down as the world went virtual and individuals and families committed to isolation in hopes of limiting the spread of the COVID-19 virus.

But this idea of using social circumstances to affect physical health is not a new concept. The impact social interactions and situations have on the medical world goes beyond preventing infectious disease and can actually significantly improve a patient’s well-being when the right resources are in place.

Understanding Social Determinants of Health

Social determinants of health affect 80-90 percent1 of a person’s health outcomes and one-fifth2 of all Americans are living in environments that compromise their health. (And no… I don’t mean the busy coffee shop where someone is likely to pick up a pandemic-causing virus).

These Americans are living in situations where they lack access to housing, education, public safety, proper healthcare services, transportation, or job opportunities. There are neighborhoods where crime rates and residential segregation are so prevalent, zip codes have become a stronger predictor of overall health than both race and genetics3. And if we’re ever going to truly help these patients, we have to address the things that affect them outside hospital doors.

CMS Interoperability—A Step, Not a Solution

As an ED physician, I hear the word “interoperability” now almost daily as this month’s most trendy buzzword. The recent CMS rules on interoperability are breaking down traditional silos between hospitals, post-acute facilities, primary care physicians, and others—so that when patients leave my care in the hospital, the next provider to care for them will have exactly the insights needed to ensure a smooth recovery.

Grateful as I am for this progress, I’d like to argue that these rules are a step—and not a solution—in providing better care for our vulnerable patient populations.

Interoperability is only as effective as the people it connects. Traditional healthcare teams alone represent a small percentage of what impacts a patient’s wellbeing. For interoperability to be effective, it has to facilitate communication beyond the boundaries of traditional healthcare into the communities that these patients call home.

Stepping Outside Traditional Medical Community

When I founded Community Based Care Solutions, I wanted to close the gaps I saw in traditional healthcare models. I recognized that while hospitals, health systems, and health plans work to care for the unique needs of each patient, without the insight and support of a community care team their effectiveness is limited and may come at a high financial cost.

Our social workers have been able to see the power interoperability facilitates using a real-time, ADT-based care collaboration platform—Collective Medical. The platform’s notification system sends messages directly to our case managers, letting them know where their patient is, so they can meet the patient at the point-of-care and proactively work with that patient to connect him or her to the right resources for optimal care—despite any challenges posed by existing social determinants.

For example, half4 of state and federal US prisoners have a reported chronic condition—including cancer, heart-related problems, diabetes, kidney problems, arthritis, asthma, and others. When these individuals leave the prison system and return to civilian life, their transition from correctional healthcare to traditional healthcare systems is often difficult and results in their condition worsening, leading the individual to seek otherwise preventable emergency care.

When case managers are notified and able to work with a patient—in the prison and before release—to complete appropriate Medicaid paperwork, set up and arrange transportation for needed follow-up visits with a traditional PCP or specialist, and ensure housing has been squared away, the patient’s outcomes improve significantly.

Meeting the Homelessness Crisis

Over the past two years, homelessness has been rising, reaching over an estimated 560,000 last year.5 Of these individuals, roughly 40 percent visit the ED at least once a year, with 8 percent accounting for 54 percent of all visits.6 This is due largely to their unstable living situation and the health conditions those conditions cause or exacerbate.

Including housing resources as part of the interoperable care management system can significantly reduce ED utilization for patients experiencing homelessness and lead to better long-term outcomes. With interoperable homelessness support systems, our case managers know where patients are going, confirm that they have a living situation suitable to any existing chronic conditions, and maintain appropriate follow-up contact for continued health.

While finding long-term housing arrangements can be challenging, even small changes can be a great start. For one of our clients, simply negotiating four guaranteed respite beds within a local shelter saved $3 million in unnecessary ED care within one year.

The Right Direction

While we have a long way to go in obtaining true interoperability between all needed parties, the CMS rules allow us to make a step in the right direction. Starting small, and growing the programs as we learn, will get us where we need to go more quickly and effectively than waiting for the day when we magically have a solution for all the complexities of patient care.

As we do what we can, recognize shortcomings, and strive to address social determinants—we will be able to not only improve the medical care given, but the lasting outcomes thereof. And the progress we see in our patients, our hospitals, and our communities will improve exponentially.

Dr. Enrique Enguidanos has over 20 years of clinical experience in Emergency Medicine—much of which has been spent also serving in organizational and systems management roles. As CEO of Community Based Care Solutions and a practicing ED physician, he has spent over a decade developing and fine-tuning systems of care and community management systems that have proven very effective for frequent utilizers. He has organized these systems in a manner that allows CBCS to continuously reproduce care results across varying communities and health care systems.