Written for Alejandro Quiroga, MD, Senior Vice President, Population Health
It’s no secret that how we live determines how well we live. Non-medical factors such as economic stability, education access and community support determine approximately 70-80% of health outcomes. As health care providers, identifying these “social determinants of health” is usually less complicated than addressing and solving for them. To optimize care for our patients, we need a complete picture of their clinical, behavioral and social risk factors. It is a whole-person, value-based approach to care.
This challenge is precisely why we introduced the “Blue R.” Spectrum Health patients enrolled in risk contracts or value programs (a population of about 240,000 people) will now be identified on their Epic storyboards with a banner that reads “Blue R (Risk Contract)” to signify that they may benefit from access to care management programs. Hovering over this banner will bring up further information on the risk contract or value program.
If during the screening process a patient with the Blue R tag discloses a barrier to optimal health – or if one is discovered by their care team – team members can then refer them to the Blue R Resource group by phone, through email, or within Epic. From there, one of three dedicated Community Health Workers (CHWs) will reach out to the patient within three business days to give them the tools they need to live better. These CHWs can also connect patients to licensed medical social workers and registered nurse care managers, and will follow up with patients to make sure their needs are met.
The Blue R was piloted in March of this year by care management teams at select Spectrum Health practices, and a wider launch across primary care offices kicked off in June. In that time, the Blue R Resource group has outreached to about 100 patients and have made more than 500 patient contacts. Most referrals have been for transportation, housing, financial resource strain, stress and food insecurity.
The Blue R launch would not have been possible without the Spectrum Health Foundation for its assistance in solutioning, the primary care operations team and Stacey Brummel, senior director, Population Health. For questions, please contact Erica Auger, director, care management, or Sarah Pentoney, manager, care coordination.
Meet the Blue R Resource Community Health Workers:
Wendy W.
“Overall health is so much more than just medical. We make sure our patients’ basic needs are met at home so that they can heal in all areas of their lives.”
KAYLEE J.
”I’m hopeful that I can help our patients not be so afraid of what can be a big scary medical system. I want to get as many people connected to as many resources as possible.”
Omar D.
“My family had economic troubles when I was growing up, and we faced a lot of the same barriers our patients face. People helped us back then, so I want to provide that same service to others.”
Barriers and Resources Available:
Transportation: Connection with community programs, local transportation assistance, gas cards
Medication: Connection and assistance with prescription assistance programs and discounts, short term direct assistance
Food insecurity: Referrals to free and discounted food resources, connections to community programs (Meals on Wheels, WIC, Supplemental Nutrition Assistance Program (SNAP), etc.)
Utility assistance: Support and navigation to address access to needed utilities (phone, water, gas/electric)
Stable housing: Referral and support to navigate housing concerns from conditions impacting health (air quality, pests, disrepair, etc.) to being unhoused
Disease monitoring equipment: Direct assistance obtaining recommended scales, blood pressure cuffs, etc.