Dell Medical School builds technology to connect patients to social services

Imagine bringing your wheezing child to the pediatrician and being told the problem is asthma — then being asked about your home environment and learning that the mold in your apartment might be making it worse. You’re given a sheet of resources that might be able to help you find a safer apartment, but you can’t seem to get connected to them.

Or imagine that you go to your family physician and learn that you have diabetes and need to change your diet. But healthy food is expensive, and you live in a food desert, where the nearest grocery store is not within walking distance. You need connection to a food bank or food pantry and help to learn whether you qualify for Supplemental Nutrition Assistance Program benefits, but a language barrier and the hours you work make that difficult.

Dell Medical School at the University of Texas is piloting technology to help close the loop between medical clinics and social services providers. The technology is a bridge between the different technology systems within which they operate.

In the patient’s medical records system, a health care provider will be able to make a referral with the click of a button and send all the information on that patient to a social services agency. The agency can then notify the medical provider that the patient has indeed been connected and is now receiving services, or that it wasn’t able to help the patient.

The data remain compliant with the Health Insurance Portability and Accountability Act because of the way information is sent and the fact that sending it requires patient consent.

The bridge is being created between electronic health record systems with help from the Austin nonprofit Integrated Care Collaboration and the social services directories connected by Austin-based (formerly called findhelp) and UniteUs, a popular social services platform elsewhere.

Dr. Anjum Khurshid, associate professor and director of data integration in the department of population health at Dell Medical School, leads this work and said we can think of it as building the framework for multiple information systems to talk to one another.

It’s a two-year pilot. In 2022, it will be tested in Austin by People’s Community Clinic, a federally qualified health center, and Integral Care, the mental health authority of Travis County. In 2023, it will be rolled out in El Paso and New Orleans to make sure it has a universal application rather than just working in Central Texas.

Researchers want it to be scalable and standardized to any community that wants it, Khurshid said.

“We’re very excited to give our community a chance to address the needs of the underserved community,” Khurshid said. They also hope to “contribute to the national effort from just a treatment model of health care within four walls of hospitals and clinics to thinking of individuals and where health happens” — at home.

It’s being funded by a $998,118 grant by the Office of the National Coordinator for Health Information Technology at the US. Department of Health and Human Services. Earlier work was done with a grant from the Michael and Susan Dell Foundation.

On the patient side, an app is being built that will allow patients to see all of their health portals in one place and log into them in one place. They’ll also be able to see all of their social services referrals and track what is happening with them.

“We have to build this for those who need it the most: the underrepresented,” Khurshid said.

The bridge is also being designed to minimize the frustration of having to fill out the same information on multiple forms repeatedly. The clinic will be able to send all the patient’s information to multiple social services providers.

The actual implementation of this bridge will happen at the beginning of the year.

Traditionally, People’s Community Clinic finds out what social services patients need either because a patient brings it up or through specific questions asked during medical visits.

Before People’s starting using the first version, which is connected to, the clinician would give the person a paper with some resources if it wasn’t an emergency or get a community health worker involved if it was an immediate need.
“There are so many barriers to just getting assistance,” said Cherelle VanBrakle, director of health promotion and community advocacy at People’s.

If one of the medical assistants or community health workers can go ahead and send all the information to a social services organization on the patient’s behalf, “it takes barriers off,” she said.

Currently, even if it helps a patient fill out all the forms, People’s wouldn’t know whether it resulted in the person getting services.

“Right now, we typically don’t find out if they haven’t successfully navigated this system until they come back,” said Dr. Louis Appel, chief medical officer and director of pediatrics at People’s. “This will at least let us know in real time whether a connection has been made.

“People are much more likely to engage when you’re helping navigate that process rather than just giving them a piece of paper with a phone number.”

Integral Care sees people all the time who need more than medical care, said Dr. Kathleen Casey, director of clinical innovation and development at Integral Care. She gives the example of one patient who was having trouble meeting her basic needs, including her husband’s daily cardiac care treatments, with just disability benefits. “We were able to, through our connections, help to connect her to an organization that helps folks pay their utility bills,” she said, but that takes time.

The Integral Care staff is looking forward to “a more seamless connection” that “enhances the efficiency and effectiveness of our clinicians,” Casey said. “They want to serve more people and be assured that people who need transportation and housing to get back on their feet are receiving the help they need.”

For Integral Care’s mobile crisis outreach team, this could be especially important to quickly see that an individual’s basic needs have been resolved, Casey said. The crisis team and the social services provider wouldn’t be spending their time trying to reach each other, she said. If it frees up time, Integral Care’s staff might be able to serve more people beyond the 30,000 it helps every year.