Hixny's SMART on FHIR App Opens More Doors to Social Care

Surprisingly, the top three indicators of life expectancy in the U.S. for a given population are per capita nursing home residency, mental health challenges, and prevalence of tooth loss¹. The income level, access to care, stress, and other social factors behind these indicators have a greater impact on health than genetics or access to healthcare services². However, historically, social determinants of health have not received enough attention in clinical care.

What if we simplified getting upstream of costly health problems to address the social determinants first? A logical place to assess the need for social care is during healthcare encounters. But clinicians have little time to do assessments in their usual workflow, and few know where or how to make social care referrals. Now, in Upstate New York, Hixny health information network (HIN) and Healthy Alliance, a social services coordinator, have combined forces for a solution to this problem.

The Hixny HIN is built on InterSystems HealthShare® and is available in every hospital and most care provider offices in the greater Capital and North Country regions of New York state. Grants from the state to Hixny funded software development of a social referral capability within the HIE, and outreach to clinicians to encourage its use. “With Hixny’s broad reach into the healthcare community, it made sense to include a social referral capability,” said Mark McKinney, Hixny CEO. “One of the first things we needed was a directory – who are the social care providers, what do they deliver, and where are they located.” The search for a directory led Hixny to Healthy Alliance. McKinney explained, “They already had the directory, and staff who know how to match people with the services they need, closest to where they live.”

The result of this collaboration is a SMART on FHIR® app that plugs into HealthShare and displays a patient’s social and medical history side by side whenever a clinician views Hixny’s comprehensive patient record, either directly within their EHR or via Hixny’s provider portal. Without having to leave their usual workflow, clinicians can make a referral for social care in one of two ways:

• Entering details on the needs of the patient, such as food assistance or housing, and letting the Hixny technology fill in the patient demographics from the HealthShare record. Once the clinician has the patient’s verbal approval, the request is sent to Healthy Alliance.
  
• Clinicians already familiar with social service providers and what they offer can select a specific community-based organization (CBO) by name. Or they can use the app’s search function to identify CBOs based on location, patient demographics, and patient needs. This request for services is also routed through Healthy Alliance.

In the first case, Healthy Alliance experts match the patient with the CBO that can best meet their needs and manage the referral end-to-end. In the second case, Healthy Alliance follows up with the selected CBO to confirm the referral has been received and the patient contacted. In both cases, Healthy Alliance closes the referral loop by sending outcome data back to Hixny and the referring clinician. “Since the app went live in March 2022, 92% of referrals have used the first option and let Healthy Alliance match patients with CBOs,” noted McKinney. “It is a big ‘Easy Button’ for providers. One or two clicks, the application completes all the information, and the provider hits ‘send.’ All done in under a minute.”

The app includes guidelines for making good social care referrals and when to make them. But Hixny did not provide any training on how to use it. “We believe that if you have to explain it to somebody, it’s too complicated,” said Julia Prusik, Manager of Product Development at Hixny. Instead, Hixny notified and reminded providers that the tool was available and let them come to it and organically work through it in their practice. “One user made 75 referrals in the first 3 months,” Prusik said. “We were so impressed by what she was doing. She said that she had needed this capability for so long, and immediately was able to use it.”

Addressing the actual workflow needs of providers was critical to the app’s success. “We worked with providers, care managers, and others who were already using social referral technology to see what was great about their process, and what barriers remained,” Prusik said. “We integrated their feedback directly into what we developed.”

McKinney explained that Hixny’s goal wasn’t to replace existing social care referral systems. “The goal here is to create more doors to the same location – the government programs, churches, schools, Medicaid, food pantries, mental health, and other available resources,” he said.

Lynne Olney, Chief Transformation Officer at Healthy Alliance, noted that social care is becoming a requirement for certain payment programs and certifications, such as those through CMS and NCQA. “More and more healthcare organizations will need to show they’re looking at patients through a health equity and social care lens,” she said. “Working with Hixny, we’re making the right thing to do easy to do.”