Hospital systems around the world share a common problem: a repetitive cycle of readmissions. Research shows there are a variety of reasons people end up returning to the hospital following discharge, including health complications and type of insurance. Then there are reasons that tend to impact vulnerable populations such as homelessness, a lack of transportation, the inability to pay for medications and hunger.
To ensure patients in the Streator community are connected to organizations that serve these needs, OSF HealthCare, through OSF Innovation, adopted software developed by Pieces Technologies. Pieces Iris is a cloud-based case management platform that allows health care facilities to refer patients to community-based organizations that address a variety of needs. The technology also facilitates ongoing communication to make sure patients stay connected.
“The OSF Innovation Partnerships team chose to launch this software at the OSF HealthCare Center for Health – Streator because of its new, sustainable model for health care that focuses on care for the whole person and establishing a healthier community,” said Matthew Warrens, vice president of innovation partnerships for OSF HealthCare.
OSF HealthCare has signed on a number of social service agencies to participate in the launch of Pieces Iris. These include A Servant’s Heart, BEST Inc., LaSalle County Health Department, Safe Journeys (formerly known as ADV & SAS), Streator Salvation Army, Streator Township High School, Tri-County Opportunities Council and the YMCA in Streator and Ottawa.
As clinicians within OSF HealthCare Center for Health – Streator identify patients in need of services, they can send referrals to the organizations using the Iris software. Those social service groups then help patients with whatever needs they may have, whether it be finding a place to sleep or getting access to healthy foods and exercise.
These groups can also easily communicate with each other to discuss what services they have offered and can even invite other community organizations to participate. The idea is to build a community of social service groups that can work together and raise their effectiveness to meet community needs.
“When communication and collaboration come together, we understand our patients and their needs so much better,” said Ken Beutke, president, OSF HealthCare Center for Health – Streator. “We discover opportunities that were not being addressed, and support one another in achieving common clinical goals. Using Pieces Iris to get a patient connected to healthy food or safe housing through community-based organizations expands the scope of our service and has positive impacts on clinical outcomes.”
In addition, Pieces Iris is monitoring all of this activity to ensure the OSF Center for Health is impacting patient outcomes. Complex care managers at the facility can also track whether their patients are following through with referrals. If not, they can reach out to the patient with an intervention to re-engage them.
As OSF HealthCare works to redefine the rural health care model to focus on health and wellness, it’s imperative to tackle those issues outside of health care that are negatively impacting a patient’s ability to be healthy. However, one health care organization can’t do it alone.
That’s why it’s partnering with communities like Streator and local social service organizations to help better target those with the most needs, not only ensuring the health of an individual but of the entire community.
Pieces Iris is just one of the many solutions brought forth by the continued efforts of OSF Innovation to partner locally, regionally and nationally to solve the most complex challenges in health care. This software has not only made communication easier between the OSF Center for Health and social service organizations in Streator, it’s more importantly connecting individuals to the services they need to live healthier lives.