Posted on: July 5, 2022

In my last blog, I introduced the importance of addressing social determinants of health (SDoH) within the context of interaction between a medical provider and a patient, and the necessity of making an efficient and simple process for providers to refer patients for social care.

I can now say that Hixny has created an innovative and valuable “easy button” that gives providers the ability to connect a patient to these services—or to refer a patient for social assessment and assistance through Healthy Alliance—from within their own workflow.

We’re solving a problem many providers didn’t even realized they had—that is, knowing how and where to refer patients who need assistance overcoming SDoH. Often times, medical providers may recognize a patient has needs that extend beyond the exam room—like food insecurity—but either aren’t sure how to go about getting the patient help or don’t have access to existing systems that connect to those resources.

With Hixny available in every hospital and most medical care provider offices in the greater Capital Region and North Country, our broad reach into the community meant building a social referral capability into the health information network (HIN) made sense. And it’s working. Nearly all referrals so far have come from providers who do not have access to other social resource referral systems.

How Does It Work?

When a clinical provider views Hixny’s patient record snapshot, whether embedded in their electronic health records system (EHR) or through Hixny’s online provider portal, they see the patient’s clinical and social history side by side and can make a referral from the same screen.

Because the provider doesn’t have to sign on to other systems or leave their workflow to view data and make a referral to the Healthy Alliance network, they’re empowered to take immediate action when it’s appropriate.

    1. After recognizing their patient needs help with a social need, the provider can choose to make a referral in one of two ways through Hixny:
        • By selecting a specific community-based organization (CBO) to receive the referral. The provider can search for an organization by name, which is helpful if they know one that can best meet the need of their patient or if the patient would like to work with a specific organization. Alternatively, the search functionality works to identify an organization based on demographics and factors such as county or need, and even includes a map for easy reference if something as specific as street address needs to be considered.
        • By leaving CBO selection up to the experts at Healthy Alliance’s Referral Coordination Center. Instead of searching for an organization, the provider enters the detailed needs of the patient. Since the platform went live in March 2022, 92 percent of referrals use this second option.
    2. The provider obtains verbal consent from the patient indicating that they understand that they will be contacted by a CBO. The patients’ information is automatically drawn from Hixny, saving the provider valuable time. They only need to identify the specific social care service(s) needed—such as food assistance or transportation—and confirm the demographics.
    3. All referrals, once submitted, go directly to the Coordination Center. If a specific organization was selected by the referring provider, the Coordination Center follows up with that organization to confirm they received the referral and have contacted the patient. For referrals made to the Coordination Center, experts identify the appropriate social care organization and manage the referral using existing systems. In both instances, the follow-up done by the Coordination Center prevents patients from falling through the cracks.

To close the loop on referrals, Healthy Alliance currently makes outcome data available to providers through Hixny using a manual process. Together, we are pursuing an interoperable solution that will allow this information to flow freely, speeding up the process and further enhancing the existing integration of outcomes measurement and near-real-time analytics.

We’re excited about the possibilities this collaboration opens for the integration of social and clinical care. We also recognize some of this technology is new to healthcare, and to fully integrate the two modes of care requires continued innovation. We are dedicated to this ongoing development and look forward to its evolution and positive impact on health equity.

Hixny will be performing extended maintenance beginning Thursday, December 31 through Friday, January 1. During this time, all services
will be impacted and unavailable—including access to the provider portal.
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