Whole Person Care
Whole person care (WPC) combines health care, behavioral health, and social care services. While WPC means providing care for all persons, vulnerable populations with unmet needs are at the greatest risk of adverse events.
Also known as safety net populations, vulnerable individuals are medically and economically fragile due to health and social issues. The diagnosis of multiple chronic illnesses, mental illness, substance abuse disorders, or homelessness lead to frequent hospital emergency room visits.
Physical health and gaps in social needs result in high costs for local communities, payers, healthcare systems, and the government. Because of social or financial challenges, vulnerable individuals may be difficult to contact by telephone or other means. They also have lower participation in health and social programs.
Difficulty reaching and establishing relationships means that integrating care requires consistent and coordinated care efforts by providers.
SDOH and HRSN
The good news is that health-related social needs—also called social determinants of health—are receiving more attention. CMS, government, state health and human services offices, and local organizations are coordinating efforts to address social determinants of health.
Social organizations focusing on food insecurity, homelessness, transportation, mental illness, trauma or abuse, income, and benefits access understand how these aspects affect overall health. For example, income challenges can relate to transportation difficulties making it difficult to get to work or access services.
Clinicians and health care providers want to help patients with SDOH concerns. However, time pressures and reporting requirements make the time commitment to assess social needs challenging.
Doctors also worry about making referrals to community services that are out of their expertise. Additionally, concerns exist about referring patients to programs with long wait lists.
The Path to Support Whole Person Care
While there are many factors to provide whole person care, data interoperability is a basic tenet of healthcare. Unfortunately, clinical and social organization data exchange and software programs do not always speak the same language. This gap makes data transfer difficult, time-consuming, or impossible.
Sharing healthcare data supports health outcomes and the no-wrong-door approach. Providers like EHRs (electronic health record systems), HIEs (health information exchanges), and government, payer, provider, and community organizations can combine whole person care efforts.
However, a lack of organizational buy-in to integrate data systems can stall progress even when solutions are available. Organizations may also need to change internal processes to increase outreach beyond in-network providers.
Establishing relationships with out-of-network and social care providers is critical to providing whole person care. NinePatch software solutions support care coordination and simplify data transfer. In addition, community convener services assist with partnership building, program communication, outreach, and governance.
NinePatch SDOH Solutions
NinePatch® Whole Person Care is a second-generation software solution for health and social care providers. This patient-centered program design improves beneficiary health by facilitating care coordination, resource identification, and closed-loop referrals.
Program features, including enter once interoperability, make it easy for users to:
- Assess health, behavioral, and social needs using a variety of assessment tools
- Gain consent to share the necessary information for interdisciplinary team (IDT) involvement
- Visually identify and prioritize complex client and patient needs
- Identify services and supports not included in standard health insurance benefit programs
- Increase care team communication and understanding of how social determinants of health affect chronic disease diagnosis and management
- Make clinical and social referrals that close the loop so that users know who is providing services and can monitor patient and client progress
- Follow patient care by receiving admit, discharge, transfer (ADT) notifications
- Communicate with care team members and program beneficiaries to maintain engagement
- Share data and documents to eliminate asking beneficiaries to share or repeat information
The long-term benefits of implementing whole person care have far-reaching impacts on public health initiatives. Whole person care initiatives that reduce healthcare costs and improve health and well-being translate to other populations.
By addressing the needs of the most vulnerable populations—everyone benefits.
Whole Person Care in Action
The implementation of Whole Person Care Pilot Programs funded by CMS is showing results. Funding by the Centers for Medicare and Medicaid Services (CMS) began over five years ago.
The actions of community organizations offer valuable results and insights. A few examples include:
- Increased client engagement. Care coordination teams partnered with the Sprint Corporation and provided free refurbished smartphones for a low monthly fee.
- Reduced homelessness and extended service access. Safe overnight parking areas increased contact with community organizations.
- Prevented housing evictions due to support from case managers and legal services.
Results from five years of the CMS Accountable Healthcare Communities Model confirm progress with health-related social needs screening, referral, and care navigation. Participating organizations were Accountable Care Organizations (ACOs), Medicaid Managed Care, Medicaid health homes, and community-based services.
Advancing Social and Clinical Care
Cross-industry collaboration is critical to advance whole person care. While buying or building is a trend, health and social organizations that join to link value-based and social care will lead by example.
Health systems and payers who create shared reimbursement opportunities with CBOs will deliver proven results. At the same time, community-based organizations that proactively approach healthcare organizations to create revenue-sharing opportunities will advance SDOH efforts in local communities.
The result is a win-win for health and social care organizations and communities. Efforts to promote access to health care reduce healthcare disparities for all.