The Impact of Social Determinants of Health
There has been growing awareness among healthcare providers as well as social workers that unmet social needs, often called social determinants of health (SDOH), negatively impact health outcomes. Socioeconomic factors and physical environment can impact a person’s health by as much as 50%. For example:
- Food insecurity correlates to higher levels of diabetes, hypertension and heart failure
- Housing instability factors into lower treatment adherence
- Transportation barriers result in missed appointments, delayed care and lower medication compliance
GaHIN already serves as a trusted network that facilitates the use and secure exchange of patient health information statewide. Now GaHIN is expanding its role by connecting health and social care systems that protects patient health information while creating a closed-loop referral system to social care organizations.
Providers caring for patients in need may make referrals for social care services, but often these referrals are not acted upon. The patient may not have transportation to get to a food bank, the ability to easily make or receive calls, or the tenacity to talk with multiple departments or agencies. Closed-loop referrals alert the social service provider of the need and then confirm that the connection has been made.
GeorgiaUnify® is an innovative social care integration platform (SCIP) that leverages GaHIN’s network and technology platform to allow health systems, public health agencies, providers and hospitals to exchange information and coordinate care with a wide range of social care organizations.
GeorgiaUnify supports whole person care by integrating social care data with clinical data to enable better access to services and improve care outcomes. The GeorgiaUnify platform facilitates referrals and coordination of services for effective whole person care throughout the community.
In 2023, GaHIN received a grant to fund a pilot project to demonstrate the feasibility and value of a closed-loop referral service that supports social care integration between healthcare organizations and community-based organizations. The insights, technology and best practices developed through the grant and pilot program will lay the foundation for broader expansion across the state of Georgia. Next steps will include identifying care and services communities and using the technology to create closed-loop referral networks on a community-by-community basis.
What Capabilities Does GeorgiaUnify Offer?
Social Risk Screenings – Social care assessment and/or screening data on an individual captured and/or analyzed to determine risks and needs. GaHIN can aggregate, link and share SDOH screening data.
Referral Management – Ability to send/receive referrals, track status, and close the loop. GaHIN can support interoperability of referrals and connect referral platforms for stakeholders in the state.
Resource Directory – Searchable directory of service providers across domains. GaHIN can work with social care stakeholders to build out and maintain a resource directory.
Reporting and Analytics – Capability to generate reports and engage in data analytics. GaHIN can collaborate to develop reporting and analytics capabilities for social care stakeholders.
Longitudinal Whole Person Records – Longitudinal record of an individual’s health, social and/or behavioral health data, and related information connecting data from a patient’s multiple providers and health services. GaHIN could integrate cross-sector data on an individual for whole person care.