Building the infrastructure to care for the most vulnerable

Research indicates social determinants of health such as income, education level, access to food and environment play a major role in an individual’s ability to stay healthy—even more so than health care itself. As a result, the rhetoric around addressing these factors has exploded as health care systems work to improve the health of the communities they serve.

However, reducing these disparities is a fairly new concept for many organizations and some are trying to figure out the best approaches to meet the non-clinical needs of vulnerable populations. In March 2017, OSF Innovation placed a focus on coming up with ways to better serve those who need help the most—with a focus on the elderly, rural and poor.

Over the past couple of years, we have dug into research surrounding these areas of focus; put together expert panels; pulled public data metrics in select communities; performed interviews of residents, caregivers, community-based organizations and put together priorities for OSF to tackle. This year we have spent a majority of time building the infrastructure to ensure the right people are being targeted.

Addressing basic needs

Before we begin developing new tools and technologies, we have to address our populations’ most basic needs. As an example, if we have patients telling us they don’t have continuous access to food, we need to identify who they are, document them, connect them to resources and follow-up to ensure they are getting what they need.

We are building a solid network of up-to-date health data where we can determine where our most at-risk populations are located as well as their greatest needs. With this information, we can work with cities and local organizations to prioritize the problems we want to tackle and who would benefit the most from any solutions identified.

We’ve developed and are testing software to screen individuals for factors that may be preventing them from being healthy. The idea is to make identifying social determinants as important as recording vital signs for each person who comes to a medical provider office for care. Once we get them through the door, we can connect them to services offered in their communities.

But how do we reach those who are hesitant to see a primary care physician in the first place due to a lack of trust and other issues? We plan to launch and test a Community Health Worker program, targeting vulnerable individuals who aren’t comfortable with the health care system. Community health workers are non-clinical individuals with shared life experiences and help build relationships with their fellow neighbors, addressing both clinical and non-clinical needs.

In partnership with the University of Illinois Chicago, we developed a breakthrough OSF Innovation lab where we use human-centered design and design-thinking methodologies of user research, collaboration and prototyping to understand, identify and design solutions that fit the needs of underserved populations. As part of this work, UIC faculty and both undergraduate and graduate students are helping us develop ideas to address health care challenges.

As interventions are developed and deployed we will track and evaluate whether our initiatives are positively impacting community health outcomes. In addition, we need to look to other communities that have implemented impactful solutions as guides as well as literature and education materials.

Why does this work matter?

Research suggests traditional forms of health care account for only 10 to 20% of health outcomes while social determinants account for up to 90%. If we, as a health system, hope to make a positive impact on a community’s health, we have to address those needs that are preventing people from leading healthy lives to begin with—whether it be food, housing, transportation or anything else.

However, we want to do this in the right way. That means building a strategy around social determinants of health, partnering with our communities and understanding the people we serve. This information will be valuable as OSF Innovation develops solutions that will reach every individual in each of our communities. We believe that in being intentional innovators, we can harness the future technological developments to address the root causes of health inequity.