Originally Published: August 20, 2022
Project helps Nebraskans address issues affecting their health
One of the patients Dr. Denai Gordon had been seeing for a while at Nebraska Medicine’s Durham Outpatient Center was missing a lot of appointments.
The woman had diabetes, high blood pressure and other ailments, and the missed appointments complicated the process of getting her diabetes under control.
Then Gordon, a family medicine resident, and Dr. Neil Kalsi, a family medicine physician, began participating in a pilot project through the Nebraska Health Network for a service called Community Relay. It’s an online platform that allows providers and patients alike to search for hundreds of free or low-cost community-based services, from food pantries to housing assistance.
Similarly, a recently expanded partnership between Unite Nebraska and United Way of the Midlands now allows people across Nebraska to tap a network of services, with or without referral from a health care provider, through United Way’s 211 service.
They also can get the help of a navigator in the Unite Nebraska Coordination Center. As part of the Community Relay pilot, the clinic team began giving all patients an assessment asking whether they were struggling with any of 10 categories of social determinants of health — such things as access to nutritious food, safe housing and reliable transportation that factor into health.
Gordon said the patient eventually agreed to complete the form. She had to take multiple buses to get to the clinic. She had no bed and was sleeping on the floor. Gordon logged on to the platform and sent the patient home with a list of places she could begin contacting for help, including food pantries and sources of free or low-cost furniture.
“It just really highlights how much we don’t know about our patients if we don’t ask them,” said Gordon, who also referred the patient to social workers who are helping her work through her challenges.
Both Community Relay and the expanded Unite Us program are intended to address the fact that many of the factors that play into health, including access to food and housing, happen outside clinic walls.
Unite Nebraska initially was launched in 2020 as a system that health care providers and social workers could use to refer patients for services, said Joy Doll, vice president of community programs for CyncHealth, which sponsors the program.
CyncHealth, formerly known as the Nebraska Health Information Initiative, or NEHII, has been working to link patient records collected by physicians, hospitals, pharmacists and other health care providers in Nebraska and western Iowa for more than a decade.
“But as we’ve evolved, we’ve realized there’s no wrong door for social care,” Doll said. “… This gives people direct access to those resources in a way they didn’t have before.”
Dr. Michael Romano, Nebraska Health Network’s chief medical officer, said many patients aren’t comfortable admitting to providers that they need help beyond the medical care they’re seeking. The health network was founded in 2010 by Methodist Health System and Nebraska Medicine.
In a survey the organization conducted, about two-thirds of respondents weren’t willing to talk about their needs, Romano said. A 2019 study in a journal published by the American Academy of Family Physicians found a similar breakdown.
Of those who did answer, Romano said, “Most say, ‘Thanks, but no thanks, give me someplace to go and I’ll get help myself.’”
Kalsi, the Nebraska Medicine physician, said he likes the program because it gives him an extra tool he can use at bedside.
For patients who aren’t ready to talk about other needs, he said, the screening at least opens the discussion: “We care about this just as much as we care about your blood pressure,” he said.
The team doesn’t screen who gets the form but rather gives it to every patient. Eighty percent of health outcomes, he said, depend on what happens outside the clinic. “That’s why this is so important,” Kalsi said. “If we just stick to the books, we’re not going to help anyone.”
With some patients, like the one Gordon saw, it can take time to build trust.
“My hope is that if we provide this form to everyone, again and again, that lets you know it’s OK to talk about, just like any other medical problem,” he said.
The groups each use a different technology platform to connect providers, community groups and patients.
Community Relay uses the findhelp.org platform. Romano said the organization helps hunt down and connect with the nonprofit groups and other organizations that provide services, collectively known as community benefit organizations.
The Community Relay network has grown from 1,400 organizations when it started to about 2,200 today.
United Nebraska uses a platform developed by Unite Us, a New York technology firm. The system is connected to more than 4,000 resources. It also allows providers and the community organizations to track whether patients followed up and received the help they needed. Adam Fanning, Unite Us state network director for Nebraska and Iowa, said the program reaches into Iowa.
Pam Schwalb, chief operating officer for United Way of the Midlands, said Nebraskans still can call 211 to seek help. But Nebraskans who need help also can go to Unite Nebraska or ne211.org to search for food pantries, transportation, rental assistance and other types of assistance by ZIP code.
Doll said the data collected through the platform comes back to CyncHealth, where it’s available to clinicians. That way, a provider would know a patient faces challenges, such as food insecurity, that also affect her health.
“Really, what we’re trying to do is build out an infrastructure for Nebraska and Iowa so people can get things in one place,” she said. Schwalb said United Way’s 211, which took 320,000 calls last year, has an assessment up front to determine whether someone using the system has a specific need. That way, the person can be directed to a navigator with knowledge of the issue. Recently, for instance, a user called seeking assistance with a child who was acting out. The request went to a navigator who provided a referral for the user to get help with her child. Doll said Unite Nebraska is distributing flyers with QR codes to hospitals so nurses who suspect a patient has social needs can place the flyer in the patient’s discharge papers, allowing the patient to seek help on his own. By working through United Way’s coordination center, Doll said, Unite Nebraska also has been able to gain access to the United Way’s bilingual navigators and a language line that provides interpreters covering 240 languages. Previously, some community groups rejected referrals based on language. “That’s health equity in action,” she said. The organization also has data indicating that there’s more need in the community than resources to meet it, she said. Romano said the good news is that multiple groups are working on the problem. “Ultimately,” he said, “success in all of this is, ‘Can we change some of those health outcomes to more favorable outcomes by intervening in these social needs?’”