LeadingReach News

A chronic disease management pilot program designed to digitally connect health care providers and community-based agencies reduced HF readmission rates and improved communication among care team members, according to a case study.

The South Texas Physician Alliance (STPA), an independent physician association serving the Lower Rio Grande Valley, worked with health care communication company LeadingReach to digitally coordinate care for its Heart Failure Reduction Program. The 30-day program is initiated when the hospital sends a collaborative referral for a HF patient. Care team members use a digital platform for confirming appointments, communicating issues via a team chat function and sharing documents.

The program is designed to improve overall patient well-being; however, the STPA also observed an overall reduction in HF readmission rates as well as improved care coordination across agencies, according to Sheila Magoon, MD, executive director of STPA.

Healio spoke with Magoon and Curtis Gattis, CEO and co-founder of LeadingReach, about the importance of collaborative care in HF, getting ahead of patient challenges and plans to expand the program beyond HF.

Healio: Why was there a need for this type of program, specifically for HF?

Magoon: We have had readmission issues and high admission rates in our region for many years. This issue has always been on our radar, and we have been approaching it from a variety of different standpoints. When we looked at Medicare data for HF in particular, our readmission rates ran 22% to 23% in our region. This is something we need to figure out how to fix. We chose to focus on HF for several reasons. First, it is an outpatient treatable condition most of the time. Second, HF, unlike sepsis, which also has high readmission rates, is a condition that could be more amenable to a pilot program.

Gattis: Communication has been broken in health care. We are in the business of connecting communities digitally. If you look at a typical HF patient, this work has really opened our eyes to the team-based approach that is required for it. HF requires not just the primary care physicians and the cardiologists, but subspecialists — a HF specialist, HF nurse, imaging centers, case managers, pharmacists, physical therapists and home health agencies. It is a challenge in the urban areas, but once you get down into the Lower Rio Grande Valley and overlay the social determinants of health and other unique challenges, a program like this provides a great opportunity to move the needle in a big way. If we get ahead of these challenges, we can keep these patients healthier.

Healio: How did this program come together and how does it work?

Magoon: One of our larger hospitals came to us and said, ‘We have a readmission problem.’ We said, ‘So do we.’ They are all our same patients. So, how can we fix this? We were already working with LeadingReach in the classic physician-to-physician referrals. I have seen what it can do.

At the same time, local emergency medical services initiated a community paramedic program. The hospital administrator and I started building this program out. We created a plan where the hospital case manager would identify the patients with HF while they were still in-house, and then we designed what we call a collaborative referral. That referral goes to the community paramedic. It goes to our care transitions nurse. It goes to the PCP. Then, anyone else we need to tag in who is already known to the care of that patient could be added to this referral that goes out electronically. Now, we are all held responsible to each other. We have the greater level of accountability.

We met with the other stakeholders — PCPs, community paramedics — everyone agreed this was a great opportunity. We put together tracking tools and education programs. Then we went live.

The community paramedic goes into the home twice a week. Our care transitions nurse calls patients in between. We have a weekly huddle and we ask the PCP to see the patient post-discharge within 7 days. Our increased ask was to follow up with the patients just before 30 days after discharge. The community paramedic is who is responsible for closing out that discharge.

Healio: What are the results so far?

Magoon: It is a small number of patients, but we have been able to get our readmission rate down to 13.3%. We are excited. Additionally, the local social service agency is also connected to LeadingReach. That has been a huge benefit. If the team identifies a person who cannot afford medications, we can refer them to the agency. It is all built into the platform. We have been able to address patient needs in a way we have not been before. That has been a wonderful piece to be able to pull together in a new way.

Healio: You mentioned readmission rates falling and addressing patient needs. Any other lessons learned since implementing this program?

Magoon: For the patients readmitted, we found there was often no support in the home. When there is good support in place, and we support that home support, patients tend to do better. We recognize that is a challenge.

Another challenge is end-of-life care. We want to help the patient and family better recognize that is where they are and help them through. It’s one thing to complete your advanced directive counseling, but patients need emotional and spiritual support. We recognize that we need to add that into the program, as well as behavioral health support.

Gattis: What Dr. Magoon just illustrated is the definition of the team-based approach to health care. You cannot build on programs like this one unless there is a good foundation in place to make sure the patients get what they need. We can say we have gone from 23% to 13%. Now, how do we tackle the more challenging pieces? Some patients have no support network. Some patients cannot or will not take ownership of their health. Then there are those who do want help but do not have the resources. This program gives the PCP the opportunity to hold that network accountable. Our technology allows us to monitor and see what is going on. We can see who is having staffing issues. We can monitor what is going on across the network and identify gaps in personnel and other challenges.

Healio: Are there plans to expand on this program?

Magoon: We do plan to expand and take on additional diagnoses. In addition to HF, we would like to take on sepsis follow-up. That is our other big primary diagnosis that ends up with a readmission. We want to add a broader profile of patients and then look to continue to add additional community-based organizations, see if we can identify someone to help us with behavioral health support, as well as the additional pieces of the medical community at large that can benefit our patients. It’s all about right care, right time, right resources.

Gattis: This is exciting for us to empower these thought leaders and physician leaders in the communities we work in. We are big believers in value-based care. We want the PCPs to have the ability to be actively managing their patients’ health. If we can stop some of these problems at the PCP level and reduce specialist burden, we will have healthier communities. I love bringing our technology to the table and listening. Software never sleeps; we are always doing new things. We look at what the Dr. Magoons of the world see as the next-level challenges and we go and support efforts to make these communities thrive.

The telephone totally revolutionized the way we could communicate with people all over the world. But then came email and took it to the next level. And then came text messaging. And then came video calls. And so on…What’s next? What’s just around the corner?

In this interview series, called ‘The Future Of Communication Technology’ we are interviewing leaders of tech or telecom companies who are helping to develop emerging communication technologies and the next generation of how we communicate and connect with each other.

As a part of this series, I had the pleasure of interviewing Curtis Gattis.

An experienced CEO and Business Development Executive with a sincere passion for building companies and driving enterprise value. A proven track record in bringing products to market, developing teams and delivering revenue.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

Like many people, I had a non-linear path to my current role as Co-Founder and CEO of a healthcare technology company. Most of my career was spent in sales and sales management at venture-backed, high-growth technology companies outside of the healthcare space. In 2009, I began looking for a new challenge — specifically, I wanted to build a sustainable company founded on a unique, innovative business model to deliver something of great value to customers.

That’s when I stumbled on a creative agency in Texas that was incubating a live-event engagement technology for conferences and tradeshows. After joining the agency to help explore the technology’s potential, a chance conversation with one of our clients opened our eyes to the ways in which the technology could benefit the healthcare industry to improve communication with patients and providers — and thus LeadingReach as it is today, was born.

As someone with no healthcare background, if you told me 13 years ago what I’d be doing today I would have thought you were crazy. I had no idea how complex and difficult the challenges in the healthcare industry are to solve, nor how much of an opportunity we had to truly improve people’s lives and make an overall impact on the communities they live in.

Can you share the most interesting story that happened to you since you began your career?

I would say it is the series of “lightning strikes” that got us to where we are today. In particular, our initial foray into healthcare as described above. I was randomly tagging along with our video production crew to a shoot at a local hospital when I met their social media manager. A chance conversation about our technology led to a meeting with their CIO about how we could help bariatric patients by digitally sending them forms, driving directions, videos and other preoperative materials to improve their experience and ultimately their outcomes as well. Had that conversation never taken place, we probably would have never gone down this path.

It is wild to think that everything we have created most likely would not have happened but for that unlikely meeting. For me, it reinforces the importance of being present and giving full attention to the people and situation around you at all times. You could say my life’s work can be drawn back to that moment. Interestingly enough, even though I never worked with that social media manager and he moved to another state, we became good friends and we still talk all the time.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

My favorite quote is by Henry Ford: “Whether you think you can, or you think you can’t — you’re right.”

I’m a big believer in the power of intention and the law of attraction. I try to live my life in a way that draws positivity and opportunity through good intentions and hard work. I have been very blessed and have had a fulfilling career working with amazing and talented people at every company I’ve been a part of. Beyond that, I have been incredibly fortunate to be able to help build LeadingReach into what it is today. We have such a wonderful team of individuals who genuinely care about each other and our work. I like to say “our culture manages itself” and it is certainly bigger than me and my co-founder Clint Smith. The company has reached a size and maturity where you can lose some of the things that make working in a “startup” so fun and rewarding. We have managed to capture that feeling and buzz and make it part of who we are today. Our team doubled in size in 2021, which means due to the pandemic I have not met over half of our company in person, and yet our company and culture are stronger than ever.

As I mentioned before, in 2009, I was ready for a new challenge and wanted to build a sustainable company founded on a unique, innovative business model to deliver something of great value to customers. That’s it, no industry focus or product ideas, but I knew I believed in my ability to build teams, bring products to market and deliver revenue. I just wanted to build a cool company but had no idea what we were going to do. I could not even spell HIPAA at the time… but I knew I could build a business if we focused on solving problems and helping bring great value to customers. In my experience, “Whether you think you can, or you think you can’t” makes all the difference between success and failure.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

That one is easy, my father. He is an incredible man and an absolute inspiration for me every single day. He is 82 years old and still as sharp as a tack. He is also a great Horatio Alger type of character. Dictionary.com’s definition of Horatio Alger, “of or characteristic of the heroes in the novels of Horatio Alger, who begin life in poverty and achieve success and wealth through honesty, hard work, and virtuous behavior,” sums him up perfectly.

I have newspaper clippings from the 1940s of him winning a tennis championship in bare feet, because they couldn’t afford tennis shoes for him as a child. He was the son of educators and was born in 1939, He came from very humble beginnings, and was taught to work hard and treat people with love and respect. He worked for ExxonMobil his entire career and ended up as a senior executive with a tremendous amount of responsibility. He is a very spiritual and religious man who inspires everyone around him and is respected by everyone he knows. I won the lotto by being born to him and my mom. He is the best father I could ever ask for and I’m so fortunate to have him as my role model still to this day.

How have you used your success to bring goodness to the world?

Outside of the various charities that my wife and I support, our favorite is Austin Pets Alive which is a fantastic local nonprofit which is known for innovative lifesaving programs designed to save the animals most at risk of euthanasia. So far over 100,000 pets’ lives have been saved since 2008! I’d point to LeadingReach as my personal favorite example. Again, I just wanted to build a “cool” company where people would be passionate about their work and be in a place where they could be the absolute best version of themselves. I’m happy to say that LeadingReach is exactly that place. Our culture is our secret weapon and everyone at our company is there because they want to be there. If you’re not a good team player and don’t bring your “A-Game” on a consistent basis, then LeadingReach is not a good fit for you. However, if you love competition and working with others to solve very difficult problems, then LeadingReach just might be your favorite place to work. We have a number of team members who have been there since the very beginning and we’re blessed to have them. The core of this team is so incredibly tight and has been through so much together over the years. Weddings, funerals, so many babies, and countless fun days and nights hanging out and just having a good time.

I have been blessed beyond measure to have a hand in creating that environment. It is without a doubt the best thing I’ve been able to accomplish thus far in my career. This company has allowed me to grow in ways I hadn’t ever imagined and it is so much fun to watch others learn and grow into the best version of themselves as well.

Adding in that what we do for a living helps sick people get well, and helps healthcare organizations thrive and meet their business goals in ways never before possible is extremely rewarding. That’s the other way that I feel we are bringing goodness to the world. I didn’t wake up one day wanting to change the world of healthcare… I wanted to bring good people together and see what would happen. The fact that we are having a direct impact on millions of people is something that I never saw coming and is certainly something that is bringing goodness to the world. Our tagline is “Delivering Healthcare Happiness” and we believe we are making a difference in the lives of countless people across the country.

Ok wonderful. Let’s now shift to the main focus of our interview. Can you tell us about the cutting edge communication tech that you are working on? How do you think that will help people?

Fortunately for us, the LeadingReach value proposition is very easy to understand. We are replacing the use of the fax machine in care transitions, which still accounts for around 75% of all medical communication today. This allows providers to have complete visibility into their patient’s care journey. It’s crazy to think about, but currently, when a primary care provider wonders if their patient has followed through with booking an appointment with the specialist they had referred them to or what the outcome of that appointment was, they usually don’t know, and there isn’t an easy way for them to get answers.

Typically, PCPs give their patient a specialist’s business card and tell them the specialist’s office will call to book an appointment once they receive the patient’s medical records via fax. Most of the time, however, this process doesn’t go as planned. We’ve all been there, when you or someone you love has been told they need to see a specialist for additional care, but don’t fully understand when, where, why and how much it will cost. The easiest path is to blow off the appointment or go out of network, especially if they don’t understand the reasons why they may have been referred. Add an unreliable fax machine into the mix and this is where we see a massive breakdown in the patient journey — in fact, an astounding 50% of referral appointments never take place.

Rather than manually “faxing and forgetting,” users on the LeadingReach Network can track their patients through their care journey and communicate with the specialist’s office in real-time. Our platform can also help providers determine if a specialist is in a patient’s network, resulting in a much lower cost of care and improved patient experiences. For employers and value-based care providers, this helps them ensure their patients are getting the care they need at the highest quality and for the lowest cost. For specialists, it enables more streamlined care coordination and creates a foundation to better manage their business. Lastly, for patients, it creates a functioning health system that is much better equipped to provide them with the highest quality of care at the lowest cost with the best possible patient experience.

How do you think this might change the world?

We’ve seen incredible results across the entire healthcare industry and while we are growing rapidly, this is just the beginning. As we continue to digitize communication and connect healthcare providers we are finding more and more ways to add value and impact patient care. There are so many challenges in healthcare that can be solved by providing accountability and transparency that isn’t available when depending on faxing. Some of our customers are building major corporate initiatives on and around our technology. Those initiatives impact millions of people and help keep both patients and businesses healthy and thriving.

Keeping “Black Mirror” in mind, can you see any potential drawbacks about this technology that people should think more deeply about?

No, not at all. The fax machine was patented in 1843 with the telegraph, that’s a ridiculously long shelf life. There are no drawbacks that I can see.

Was there a “tipping point” that led you to this breakthrough? Can you tell us that story?

Yes, the tipping point for us came back in 2015 when we first learned about Value Based Care and the importance of managing patients from a holistic approach led by the primary care provider. The “ah ha” moment came when my co-founder Clint was sitting down with a brilliant primary care provider (PCP) in our hometown of Austin, Texas. The PCP said “Clint, your Patient Engagement products are great, but if you want to solve the real problem in healthcare — it’s that fax machine in the corner.” This doctor was trying to build out one of the first accountable care organizations (ACO) in Central Texas but was running up against a critical challenge — his providers and staff had no idea where their patients ended up once they left the office. “My providers spend an inordinate amount of time chasing down patient updates from specialists,” he explained, “because we’re all using different electronic medical record platforms and can’t easily share information digitally.” We realized that there would be a limit to what value based care could accomplish without a connected network of providers. It was at this point that we knew what we had to do. Within 6 months their network was connected and we knew there was a bright future for us if we could replicate that across the country. Over 40,000 connected care settings later, we have reached a tipping point and are starting to realize the power of the Network Effort that our technology has created.

What do you need to lead this technology to widespread adoption?

I think the best answer here is: Time. Our business has a unique opportunity to impact everyone in America. We are all patients and we all know there are limitless challenges in American healthcare. The good news is that our technology allows everyone to benefit from participating on the LeadingReach Network. Patients first and foremost are the biggest benefactors because they receive better care, in the appropriate care setting according to their plan design, in a more timely manner. That leads to better outcomes and healthier communities. We have talked at length about how we support providers engaging in Value Based Care models but we can and do provide equal or greater value to organizations focused on the traditional Fee For Service model. Because we have figured out a way where “everybody wins” there are very few objections we can’t address and overcome. That said, we are the first to acknowledge that change is hard and takes time so we have to be patient and just keep working hard every day to deliver healthcare happiness.

The pandemic has changed so many things about the way we behave. One of them of course, is how we work and how we communicate in our work. How do you think your innovation might be able to address the new needs that have arisen as a result of the pandemic?

We see this every day. With the recent Omicron surge, a number of healthcare clinics were closed or had people out sick. LeadingReach is a web-based HIPAA Compliant platform so a huge number of our users were able to access their referrals and keep working from home. We have been able to help healthcare providers to keep up throughout the pandemic, and I believe that will only continue as we transition into whatever happens next.

Fantastic. Here is the main question of our interview. What are your “5 Things I Wish Someone Told Me Before I Started” and why?

1. Expect the unexpected: In our company we like to compare ourselves to a Formula 1 race team. In particular we admire the cutting edge engineering and exemplary teamwork displayed in a 2-second pit stop. We make that comparison so that we are always thinking about how to make our products and processes better. Like that old Lexus tagline “The Relentless Pursuit of Perfection,” we strive every single day to find the slightest edge. Because of that, I believe we were uniquely suited to quickly adjust to the pandemic. We went from an in-person company to a remote company in one afternoon. The world changed for everyone that day and if the pandemic has taught us anything, it is we better get used to the unexpected and learn how to navigate whatever life throws at you.
2. Change takes time, especially in the healthcare industry: As mentioned above, I didn’t have a direct line to the healthcare industry and had no prior knowledge to start from. If you asked me what my biggest surprise as a business leader was about building LeadingReach, I’d tell you it would be the difficulty in working through all of the various hurdles unique to healthcare that are part of the sales cycle. Some deals take years to close, and that’s not something I was fully aware of. We all know that the healthcare industry is like no other, both from a business standpoint as well as the gratitude you receive from helping people at scale. We have put in our 10,000 hours and are seeing the fruits of 10+ years of labor but this was definitely a challenge and something I had no experience with when we started.
3. Grit is essential: Building on the previous answer, to be a successful entrepreneur having a certain level of grit is essential. A number of people have talked about the typical emotional journey for the entrepreneur, it goes something like this. In the beginning your ideas are so exciting and you just KNOW that you’re going to change the world. Then reality sets in… you’ve got rent and payroll to cover and people to hire and money to raise. That realization can lead you down into the Valley of Despair. Down there, if you’re lucky, your business Crosses The Chasm and you start to believe you can really make it as a viable business. At some point your confidence grows and you get back on the Slope of Hope. Ideally from there you keep taking everything High And To The Right and you will one day have a successful business with meaningful revenues and a large number of customers. Statistics say 90% of startups fail, with 70% of those happening within the first 5 years. You’ve got to have enough emotional grit (and hopefully an amazing group of people around you) to get through the inevitable hard times. Legend has it that in response to his generals who had declared it impossible to cross the Alps with elephants, the ancient statesman and commander in chief Hannibal said, “I will either find a way, or make one.” That’s grit!
4. Timing is critical: We started thinking about LeadingReach for healthcare back in 2011 so we have been at this a petty long time now. You never know when technology and society are aligned enough for it to break through and become adopted on a mass scale. There are many stars that have aligned themselves to make LeadingReach what it is today. From the industry currents bringing Value Based Care to more and more patients to the next generation of users now working in healthcare, timing has been a big part of our success. Even the first 5–6 years of building our company prior to the pandemic was key. The work world has forever changed and I’m SO glad we had that opportunity to build our company while we were still all in the same office. Remote work in some form or another is here to stay and our years of in person white boarding, ping ponging, hugging and high-fiving was priceless to our culture and overall success.
5. It will be worth it: The final thing I would want to hear would be the affirmation that all the blood, sweat and tears would eventually be well worth the price. Our story is far from over and we have a lot of work to do but we have made it to an exciting time in our journey… we’re well on our way up the Slope of Hope. Regardless of what happens I have been able to grow as an individual in ways I never thought possible. That alone has been worth it. To know that we have impacted the lives of tens of millions of patients and thousands of businesses is incredibly fulfilling to all of us at LeadingReach. The biggest blessing to me has been the incredible friendships that have come through this process. We have so many talented and caring people on our team and it just makes getting out of bed and going to work so much more rewarding and fun!

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

I would encourage people to strive to consider some type of meditation and mindfulness training. This has nothing to do with spirituality or religion if that’s your choice, and many forms of exercise and prayer can fall into this type of activity. If you want the world to change, it starts with each of us becoming mindful of the energy we are putting into our own heads and out into the world. The only thing we can control in this world is how we react to our environment and our experiences. Road rage is my favorite example of this. Some days you’re really agitated with traffic and other drivers and others you’re singing out loud to your favorite song on the radio completely ignoring those same things that agitated you before. What changed? Only the way you chose to respond. This applies to every single scenario in our lives. Many types of meditation practices help hone this mindfulness and it is a key foundation for acknowledging your intentions in everything you say and do. I believe if we could get more people to think and live like this then humankind would grow closer together and more loving.

How can our readers further follow your work online?

You can follow me on LinkedIn here: https://www.linkedin.com/in/curtis-gattis-2568853/

Or follow LeadingReach on LinkedIn at: https://www.linkedin.com/company/leading-reach

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.

Chronic care management has become one of the most important topics to healthcare organizations.  The move to value based care is going to require every organization to better understand how to manage chronic conditions.  Plus, things like SDoH (Social Determinants of Health) play a really important role in managing these chronic conditions effectively.

As we work to understand how chronic care management continues to evolve and mature, we sat down with Curtis Gattis, Co-Founder and CEO of LeadingReach and Dr. Jeff Bullard, MD, Chief Medical Officer and Chief Product Strategy Officer of Catalyst Health Group.  We ask them if we’ve finally turned the corner on proactively addressing chronic conditions and the state of chronic care management today.

They also share with us who is the best person to address the chronic conditions.  Is it the PCP?  Is it someone else?  Who’s on the team that’s needed to address chronic disease?  Plus, how does an overwhelmed PCP really address the SDoH challenges and what’s a model that works for addressing SDoH as part of chronic care management.

Check out the video below to learn more about how Dr. Bullard from Catalyst Health Group and Curtis Gattis from LeadingReach are working on chronic care management.

Tech-driven connectivity and collaboration tools empower primary care providers (PCPs) to shepherd patient care, while simultaneously empowering patients to make more informed and strategic decisions about their own health and care journey.

Health care, at its core, is an experience between patients and their health care providers. At worst, clunky technologies, operational processes, and reimbursement hurdles produce a fractured experience, usurping the attention that relationship-driven care needs. In an ideal scenario, those technologies, processes, and payments work seamlessly in the background, enabling the delivery of personalized care where patients are known and understood. And though even the right technology could never replace patient-provider interaction, it certainly can elevate it. Tech-driven connectivity and collaboration tools empower primary care providers to shepherd patient care, while simultaneously empowering patients to make more informed and strategic decisions about their own health and care journey.

As we continue to see new variants, subsequent delayed care and other pandemic curve balls, efficiency and optimization are the name of the game when it comes to meeting patient needs. In 2022, we’ll see more healthcare leaders focus on identifying and tracking critical conversion metrics (like their referral-to-appointment ratio and referral response rate) to ensure patients are getting the care they need rather than falling through the cracks, which happens 50 percent of the time with outdated communication processes that involve faxing.

As a result, we’ll also see more provider networks shepherding their patients towards more strategic partners and clinics and away from less responsive, less timely care. The traditional need for healthcare has not changed, even in the face of a global pandemic, but we will see an increased push to engage patients with their care, particularly when it comes medical conditions that require a team approach to healthcare.

It’s no secret that access to healthcare is a challenge for patients. And it’s becoming harder and harder for patients to get appointments with their PCP or the specialists they have been referred to for advanced care. Now more than ever providers and their staff are faced with a growing number of challenges that prevent or delay them from doing what they are all there to do: get patients in front of a doctor to determine how to get them well. One of the biggest villains in this story is the old fax machine. No matter the practice’s type or patient volume, there are so many ways things can go wrong with a fax-dependent process that is nearly impossible to standardize, has no real built-in accountability and is dependent on significant levels of coordinated communication. 

That’s why it’s vital for a practice to have processes, goals, and measurements that align with that core objective of both getting patients to schedule appointments and of course come in for their appointments. The easiest way to accomplish this is by managing the practice’s referral-to-appointment ratio, otherwise known as RTA. Aligning the staff’s objectives to optimize a practice’s RTA ratio means more patients are getting the care they need while simultaneously ensuring a practice’s financial health is secure. 

Traditional referral intake systems haven’t changed significantly in the past 30 years. Rather, they are still based on paper and fax referrals that often get lost in the shuffle of busy days and patient care needs. This reliance on old-school methods flies in the face of significant connectivity and communication adoptions that are being successfully leveraged in other industries. Between the barrage of phone calls and faxes flowing between provider offices, provider office administrators struggle to confirm patient information, locate missing labs and medical records, and keep track of inefficient and disruptive back and forth conversations to facilitate quality patient care. With disparate EHRs, scheduling software, and office procedures, provider networks have historically lacked a shared language and a standardized process too easily connect and communicate.

Under this traditional model, even in the best-organized offices, the administrative point person – the patient coordinator – deploys basic spreadsheets or a handwritten sticky note with limited sharing functionality to help make sense of the referral and health data chaos. This type of analog reporting takes hours, and the information and procedures get siloed into that individual patient coordinator’s workflow with no visibility or accountability. As this position is one of high turnover, the knowledge and process efficiency disappears with each resignation. These archaic methods often lead to patients slipping through the cracks and never getting the callbacks needed to close the loop and schedule appointments. While this is a huge issue for patients seeking critical care from providers they are referred to, this also has serious impacts on a full health system’s patient and revenue leakage. Ditching the old school model for streamlined technology can change the paradigm and enhance the care coordination process for both patients and providers.

To view the interview click below:

For South Texas Physician’s Alliance, social determinants of health referral has been a learning experience. The organization, which has joined providers across the country in efforts to address social determinants of health, knew the best solution was connecting patients to social services providers. A patient presenting with food insecurity needs a referral to a food pantry, or a patient with housing insecurity might need the help of a medical-legal partnership. But even with that strategy, organizations are facing an uphill battle, largely in terms of networking.

“There's just so much that we need to learn because it's just not an area in which medicine is used to functioning,” Sheila Magoon, MD, the executive director of South Texas Physician’s Alliance, told PatientEngagementHIT. But through an understanding of how to collect SDOH data, the pain points in social services referrals, and the types of technology and interpersonal partnerships the organization would need, South Texas Physician’s Alliance said it’s on the path to building out a strong community health network.