Because complex patients use a lot of episodic healthcare, a little social context could go a long way to improved outcomes.
Use social determinants information to better understand, predict, and control outcomes for complex patients. In offering social services information support to health plans serving dual eligible (Medi-Cal and Medicare) beneficiaries and other members, as well as our region’s hospitals, community clinics, and other safety net providers, we can supply the client-specific social context that may be missing from the patient’s self-reported history.
By sharing a commitment to avoid unnecessary inpatient readmissions, reduce length of stay (LOS), and avoid frequent emergency medical service (EMS) and Emergency Department utilization, CIE can aid in linking social services with Patient-Centered Medical Homes (PCMH) and other appropriate points along the continuum of care. Together, let’s add context to our focus on achieving the triple aim – – improved patient care experience, better population health outcomes and reduced cost can be achieved.