Chilmark Advisory Services Care Management Domain Monitor

By Matt Guldin (March 2017)

There is increasing emphasis on the social determinants of health (SDoH) and the role they play in an individual's health and subsequently, their medical care. Healthcare organizations (HCOs) and care management vendors are just starting to undertake capturing this data in more detail. The goal: futher improve a patient's overall well-being and begin forming strategic partnerships to coordinate care with relevant community and social stakeholders. 

Key Takeaways:

  • There are five core forms of social determinants of health, but other ones such as stress are increasingly being studied and recognized.
  • Operationalizing the collection of this form of patient data (storing and providing insights) at the point of care is proving to be exceedingly difficult. 
  • Few care management vendors have the ability to support a directory-level capability of relevant community and social stakeholders or enable bidirectional communication between the HCO and the social and community stakeholder regarding the status of a referral request and any associated details. 
  • Some vendors (e.g. eTransX and TAVHealth) do not have the capability to address this type of care coordination today. 
  • Salesforce is lurking and looking to use HealthCloud to partner with innovative social and community stakeholders. 
  • This is a functionality that care management vendors will have to address in the near term through buy/build/partership activity but we do not see this type of functionality being integrated more broadly across most care management vendors for at least 18-24 months. 

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