It’s a common problem a person experiencing poverty faces. Their doctor has just diagnosed them with prediabetes. They’ve been told to eat healthier foods and exercise more. They’ve also been prescribed medications to control their blood pressure and cholesterol. They’re sent home with what their physician believes are the tools to prevent full-blown diabetes.
But there are problems the doctor doesn’t know about. Our patient in question is struggling to put food on the table for their family. They are working two jobs and don’t have the time to get a workout in. And if it comes to buying meds or keeping the lights on in their home, the patient is going to keep the lights on. Before you know it, they end up in the emergency room with uncontrolled diabetes.
Whether it’s not having access to the right foods or having enough money to pay for medications, these types of social and economic drivers keep marginalized populations from being healthy. The OSF Innovation Data Science and Advanced Informatics Lab, a part of OSF HealthCare, has developed an all-encompassing solution not only to identify people at risk for poorer health outcomes but to help connect them to resources and ongoing monitoring.
OSF Community Connect
OSF Community Connect is a platform that leverages data to link OSF to people who are most in need of assistance. It can help the Ministry prioritize care and resources for the most affected communities. And it can help establish connections to care for prevention, treatment and surveillance.
“The solution was born out of the pandemic as a way to support OSF Community Health Workers (CHWs) who were digitally connecting with COVID-19 patients to assess their conditions, provide education and refer them to a provider when needed,” said Roopa Fouler, director of the Data Lab and vice president of Digital Innovation Development. “We discovered it could also be a way to reach out and maintain relationships with under-resourced communities.”
As part of a state award aimed at improving Medicaid services in Illinois, the Data Lab has expanded the platform’s capabilities to serve this population better. It’s not just for CHWs to use out in the field. The OSF Community Connect can now be used by clinicians, community-based organizations and others to carry out a number of tasks in service of patients.
“Years of background research to uncover unmet needs in our communities led us to propose the OSF Community Connect solution,” said Jon Handler, MD, senior fellow for OSF Innovation. “We then trained our teams to quickly and effectively develop, test and implement the platform. This allowed our diverse team to focus on a single, shared vision – to improve health in the communities we serve, especially for those in greatest need.”
How it works
Thinking back to the person diagnosed with prediabetes, the platform can notify a physician about socioeconomic factors that could prevent the patient from following recommendations. The doctor can then inform a CHW, using the platform, to connect their patient to a community-based organization that could help provide healthy foods and financial support to buy medications.
CHWs can also follow up on whether their patient got the help they need and send text messages when it’s time to reevaluate their condition – all through the platform.
“The possibilities are endless,” said Nick Heuermann, a strategic program manager with OSF Innovation. “Users can customize workflows in the platform to identify any patient group they want to focus on. From there, they can use the same tool to positively impact an entire population.”
So far, OSF OnCall Digital Health has adopted the OSF Community Connect platform for everything from identifying people who could benefit from remote patient monitoring to breast cancer screening outreach. The platform will also be used to support Federally Qualified Health Centers like Heartland Health Services in Peoria and Aunt Martha’s Health and Wellness in Danville as they begin including CHWs to their teams.
These CHWs will act as liaisons between these federally-backed health centers and patients who historically don’t follow through on health recommendations due to various social challenges. Their role is to connect people to community and health services using the platform.
“We’ve essentially built an electronic community health record to integrate data from multiple places,” said Foulger. “With OSF Community Connect, it should be much easier for us as a health care system to identify people in most need of our help, monitor progress and intervene when necessary. We shouldn’t have anyone falling through the cracks because of their social or economic status.”