Bridging Clinical and Social

Home visits can reveal health factors that office visits may miss. Patient Charles Sherman receives a home visit from Daneane Neyer, RN, MaineHealth ACO care managerHealth care providers understand that there’s more to a patient than his or her diagnoses. Physical exams, tests, medical history and family history all offer important information, but they don’t reveal the whole patient. For deeper insights, providers look to the broader factors that influence a patient’s health, like food security, housing, access to transportation, social isolation and other “Social Determinants of Health” recognized by the federal government and the World Health Organization. But during a typical fifteen minute office visit, these determinants can be elusive or even invisible.
The MaineHealth ACO’s Clinical Initiatives Team is working to make information about patients’ Social Determinants of Health (SDoH) more accessible to providers. Two initiatives illustrate the nature of the work, one high-tech and the other high-touch.

The Longitudinal Plan of Care

In 2017, Clinical Initiatives Team members worked with multidisciplinary and multisite stakeholders to use existing digital technology to deliver SDoH information directly into the exam room. Called the Longitudinal Plan of Care, the solution adapts the widely-used Epic electronic medical health record to automatically display any SDoH information previously entered into the system by members of the care team, including medical assistants, home health nurses and care managers. The Longitudinal Plan of Care is accessible through a view tab at the top of the record. When clicked, it reveals multiple clinical and social fields, including a social summary (what matters to the patient) and SDoH data and goals (what the patient is invested in). Fields are strategically positioned to clearly see if, for example, a patient on multiple medications may benefit from financial assistance to afford prescriptions. Recent emergency department visits and hospital admissions are displayed in a unique format, organized sequentially by most recent month.
“The Longitudinal Plan of Care is a way for all members of the care team - whether in primary, specialty or acute care – to share their deeper insights into patients’ lives and have that information display in the medical record,” says Cindy Tack, the ACO’s senior director of clinical initiatives. “It’s a prime example of bridging and aligning the clinical and social determinants of health for a more informed, patient-centered approach to care.”

Amy Wedgewood, RN
Complex Care Teams

When patients have multiple chronic conditions combined with social or economic challenges, office visits are not always sufficient for meeting their care needs. To better serve these patients, the ACO has created Complex Care Teams comprised of a nurse care manager and social worker or health guide. The teams are embedded within primary care practices in the ACO network, yet go outside the primary care office to address patient’s needs. The Complex Care Team focuses on high risk patients identified by providers or the ACO staff aided by patient data, often making a home visit to better understand the patient’s story and provide assistance.
How does this work in practice? Amy Wedgewood is an ACO nurse care manager who is part of the Complex Care Team at Southern Maine Health Care Family Practice in Saco. Dr. Anastasia Norman reports one example of Amy’s impact on a patient’s health:
A patient came to me about a month ago feeling more fatigued, ill and having falls. Lab results suggested hypothyroidism and poorly controlled diabetes. I sent Amy into her home and it came to light that the patient was mourning the loss of her husband and their wedding anniversary was coming up. After several visits with Amy, the patient decided to start taking her medications again. I saw the patient today and she brought in a log of fasting glucoses, has a pill box with her and volunteers to walk me through how she takes her medications every day to make sure she’s taking them correctly. She is currently invested in her care, getting back in shape and getting healthy again. Basically, she’s a completely different person from the woman I saw just a month ago. If Amy were a medication, I would prescribe her to every one of my patients.

Bridging Clinical and Social

Home visits can reveal health factors that office visits may miss. Patient Charles Sherman receives a home visit from Daneane Neyer, RN, MaineHealth ACO care manager
Health care providers understand that there’s more to a patient than his or her diagnoses. Physical exams, tests, medical history and family history all offer important information, but they don’t reveal the whole patient. For deeper insights, providers look to the broader factors that influence a patient’s health, like food security, housing, access to transportation, social isolation and other “Social Determinants of Health” recognized by the federal government and the World Health Organization. But during a typical fifteen minute office visit, these determinants can be elusive or even invisible.
The MaineHealth ACO’s Clinical Initiatives Team is working to make information about patients’ Social Determinants of Health (SDoH) more accessible to providers. Two initiatives illustrate the nature of the work, one high-tech and the other high-touch.

The Longitudinal Plan of Care

In 2017, Clinical Initiatives Team members worked with multidisciplinary and multisite stakeholders to use existing digital technology to deliver SDoH information directly into the exam room. Called the Longitudinal Plan of Care, the solution adapts the widely-used Epic electronic medical health record to automatically display any SDoH information previously entered into the system by members of the care team, including medical assistants, home health nurses and care managers. The Longitudinal Plan of Care is accessible through a view tab at the top of the record. When clicked, it reveals multiple clinical and social fields, including a social summary (what matters to the patient) and SDoH data and goals (what the patient is invested in). Fields are strategically positioned to clearly see if, for example, a patient on multiple medications may benefit from financial assistance to afford prescriptions. Recent emergency department visits and hospital admissions are displayed in a unique format, organized sequentially by most recent month.
“The Longitudinal Plan of Care is a way for all members of the care team - whether in primary, specialty or acute care – to share their deeper insights into patients’ lives and have that information display in the medical record,” says Cindy Tack, the ACO’s senior director of clinical initiatives. “It’s a prime example of bridging and aligning the clinical and social determinants of health for a more informed, patient-centered approach to care.”

Amy Wedgewood, RN

Complex Care Teams

When patients have multiple chronic conditions combined with social or economic challenges, office visits are not always sufficient for meeting their care needs. To better serve these patients, the ACO has created Complex Care Teams comprised of a nurse care manager and social worker or health guide. The teams are embedded within primary care practices in the ACO network, yet go outside the primary care office to address patient’s needs. The Complex Care Team focuses on high risk patients identified by providers or the ACO staff aided by patient data, often making a home visit to better understand the patient’s story and provide assistance.
How does this work in practice? Amy Wedgewood is an ACO nurse care manager who is part of the Complex Care Team at Southern Maine Health Care Family Practice in Saco. Dr. Anastasia Norman reports one example of Amy’s impact on a patient’s health:
A patient came to me about a month ago feeling more fatigued, ill and having falls. Lab results suggested hypothyroidism and poorly controlled diabetes. I sent Amy into her home and it came to light that the patient was mourning the loss of her husband and their wedding anniversary was coming up. After several visits with Amy, the patient decided to start taking her medications again. I saw the patient today and she brought in a log of fasting glucoses, has a pill box with her and volunteers to walk me through how she takes her medications every day to make sure she’s taking them correctly. She is currently invested in her care, getting back in shape and getting healthy again. Basically, she’s a completely different person from the woman I saw just a month ago. If Amy were a medication, I would prescribe her to every one of my patients.