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health lead-er

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April 10, 2013 10:05 am

It would be great if the government would work explicitly with organizations trying to ensure that patients have the basic resources, like food & utilities, they need to be healthy. Health IT could be leveraged to connect patients to already existing resources in their own communities, especially if those resources were easily accessible online. Many times patients don’t know what resources they are eligible to access- compensating lay staff to work collaboratively with clinical professionals to connect patients to these resources could go a long way toward raising the basic level of health in our country (and save us all $ in the process).

May 1, 2013 2:48 pm

I work for a NPO called Health Leads which has developed a web-based community resource database. Paired with a structured way to screen for basic resource needs & active follow-up with families, I think we have a model which leverages IT but also helps keep families connected to the clinics where they receive care. The trouble is, because this type of work is not reimbursable with the current fee for service payment structure, it is difficult to justify paying for this service for their patients.

May 1, 2013 2:57 pm

Here is an example of the type of basic resource need I am referring to: a child from a low income family has asthma, which is triggered by the cold weather. In winter-time, the child has more visits to the hospital or primary care clinic. The family is screened for basic resource needs and we learn that the heat has been shut off in their home. The family is referred to a service (such as Health Leads) with a robust database of community resources, and is connected to a resource providing utility shut-off protection services. Health Leads follows up with the family every 10 days until the resource is secured. The basic need for heat in the winter becomes one less factor in keeping this child with asthma healthy during the cold months.

May 1, 2013 3:04 pm

In the example I provide, the effect on the health care system is that the physician does not need to worry about connecting the family with heat & can focus on other reasons (if they exist) that the child’s asthma may be hard to control. If lack of heat was the primary reason, than restoring heat in the home decreases the need to use the emergency dept/primary care clinic, decreases days a parent may have to stay home from work to care for a sick child, and decreases the days a child might miss school. This can be accomplished with a technology backbone which identifies a basic resource need, facilitates referral to a service equipped to both match the patient or family with a resource in the community which can help address their need and follow-up with them until resolution is reached.

April 11, 2013 8:50 am

Welcome to Planning Room, health lead-er, and thank you for your comment. What do you think is the best way for ONC to connect the right community groups to the patients in underserved communities who do not know about the resources they are eligible to access?


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