Bringing Health Care Within Reach
Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care.
WellSpan expanded our efforts to screen patients for social barriers like food, housing and transportation. We anticipate screening more than 54% of all patients across our hospitals and outpatient services. Through communication with payors, optimal support in overcoming identified barriers can be achieved.
WellSpan's Ambulatory Collaborative Care Team (ACCT) leads our efforts to support patients in overcoming social barriers. The ACCT receives referrals from clinical care teams through a virtual outreach center known as the HUB, which is made up of nurses, social workers and outreach specialists. The team diligently works daily to process incoming referrals, perform chart reviews and engage patients to develop a comprehensive care plan.
In calendar year 2021, the HUB team processed 13,876 referrals through Epic alone, not counting referrals received directly through email or phone. In 2022, they have processed 11,054 referrals and counting.
Supporting Patients Through Partnership and Collaboration
Recently, the ACCT began working with social service providers and insurance payors with a goal to share resources, identify rising- or high-risk patients in need of care management services and connect individuals to the appropriate level of care in a more dignified and streamlined way. These efforts lay the groundwork for a shared case management approach connecting WellSpan and local social service providers in a way that allows individuals a single point of entry to easily navigate and receive help.
The Intensive Case Management (ICM) team encountered a husband and wife who were both enrolled in services. The team was in the process of helping the couple qualify for Medical Assistance/Medicaid Waiver, but documentation challenges and slow progress had led both to consider abandoning the process. They had too many other pressing concerns, not least of which was their oil tank being down to one-quarter full. With the LIHEAP program not due to start for another two months, worries about not being able to cook or to heat water was causing sleepless nights.
WellSpan social worker Mindee Conway reached out to connect with the family and help work on solutions. She not only helped the couple to call and get on the list for a LIHEAP application, but she encouraged them to phone the fuel supply company and ask about assistance programs. Mindee stayed on the line for a three-way call with the wife and the fuel company, where they learned about its "$500 Summer Supplement" program. The couple was eligible, tears of joy were shed, and $500 worth of fuel was delivered the very next day.
Medical Legal Partnership
This program partners with Mid-Penn Legal Services to help individuals who have health-harming legal needs. The program served 63 persons in York in the last year to obtain income, address landlord-tenant issues, secure government benefit and resolve housing and bankruptcy issues. Expansion efforts to other counties are underway.
WellSpan Special Programs began aligning with the strategic initiatives of the York County Reentry Coalition to support timely access to medical and behavioral health care for community reentrants, as well as to engage with vested community partners to reduce barriers related to social determinants of health. Engaging with York County Prison staff, WellSpan Special Programs has worked to develop transition plans in support of the reentrant's journey, to act as a conduit for information transparency, and to connect processes by providing support for reentering inmates presenting with medically acute needs. Outcomes include participants connected with housing, insurance, primary care, medication management and care provisioning; an 8% participant recidivism rate; and reduced hospital admissions and readmissions.