The Illinois-based health system created the innovative program during the pandemic to identify patients infected with COVID-19 and steer them to the right resources. Now it's expanding the platform to help identify underserved populations and the resources they need to improve health and wellness.
OSF Healthcare is expanding an innovative data platform developed during the pandemic to help health clinics, primary care providers and others identify Medicaid members at risk of poor health outcomes and the resources they need to improve their health.
The Peoria, Illinois-based not-for-profit Catholic healthcare system is making OSF Community Connect available to a wider range of providers in an effort to tackle social determinants of health that affect residents in surrounding communities. The tool was developed by the OSF Innovation Data Science and Advanced Informatics Lab to "help the ministry prioritize care and resources for the most affected communities."
“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,” Roopa Foulger, OSF's director of the data lab and vice president of digital innovation development, said in a recent press release. “We discovered it could also be a way to reach out and maintain relationships with under-resourced communities.”
The program is representative of the efforts of healthcare organizations across the country to address barriers to healthcare access and outcomes, especially those with non-clinical origins. They include home and family life, job status, food resources, transportation and geography, cultural norms, even digital literacy, which can impact access to telehealth.
The platform not only combs data to identify patients facing these difficulties, but looks for resources that can help them, such as remote patient monitoring, screening programs, local food banks, credit and family counseling, transportation networks and community centers.
“We’ve essentially built an electronic community health record to integrate data from multiple places,” Foulger said in the press release. “With OSF Community Connect, it should be much easier for us as a healthcare 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.”
Supported by a state award, OSF OnCall Digital Health has adapted the program to look for more than just COIVID-19 patients and resources, thus making it sustainable beyond the pandemic. It will also be used to support federally qualified health centers (FQHCs), which will work with CHWs to reach out to underserved communities and populations who often don't seek the care they need or follow up after their primary care visit.
“The possibilities are endless,” Nick Heuermann, a strategic program manager with OSF Innovation, said in the press release. “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.”
Eric Wicklund is the associate content manager and senior editor for Innovation at HealthLeaders.