IMPACT Connect aims to improve care coordination, address social determinants

A digital platform in Milwaukee, set to roll out this summer, aims to create a community information exchange to help connect people with needed services, improve care coordination and address social determinants of health like food, safe housing and transportation.

“I think there are very few things that we can say are … game changers, those things that sort of will have a community-wide impact that in all ways – diversity, equity, inclusion – really level the playing field for everyone in some way because this screening, the technology and the referral is really there for everybody,” IMPACT CEO John Hyatt said in a recent interview.

IMPACT Connect will combine a community resource database developed by IMPACT, which offers 211 services and referrals to services in southeast Wisconsin, with a platform from Chicago-based health tech company NowPow.

The effort, initiated by members of the Milwaukee Health Care Partnership, includes Froedtert & the Medical College of Wisconsin health network, Advocate Aurora Health, Children’s Wisconsin and Sixteenth Street Community Health Centers.

Hyatt spoke to Wisconsin Health News last week. Edited excerpts are below.

WHN: How did this come together? 

JH: This started really several years ago. This was started with a collection of healthcare organizations here in town and the Milwaukee Health Care Partnership.

Healthcare systems have obviously lots of patients. And a lot of patients, in addition to what their immediate medical needs are, have these other needs too, so, ‘Where are you living and is it safe? Can you pay your rent or mortgage? Do you have food in your house? Are you able to afford and pay utilities?’ Those basic kinds of things that everybody needs. And what they were discovering over time is that their medical outcomes, health outcomes were in large part determined by these other social determinants. Regardless of the treatment plan and any of the follow-up, there were limits about how far people could get with their recovery and their health. They can’t make an appointment, they can’t afford their prescription, they can’t get to therapy, they can’t do follow-up because they’re struggling with, ‘How do I put food on the table and how do I pay for utilities? And my address keeps changing because I have to keep moving from place to place.’

This has been going on for some time, and then you have the Affordable Care Act. There’s these requirements around following up with patients, this recidivism that happens in emergency rooms and hospitalizations, and the incentives for these healthcare systems to treat patients and keep them from coming back in over and over again. So all of these things sort of came together and they started thinking about, ‘What’s a strategy for that?’

We’ve worked with all of these groups for many years around the 211 and the call center, the resource database. And so we started thinking about what’s an electronic way, a piece of technology, as one part of a solution. We thought that we can create a social determinant screening tool that we would all use and throughout our organizations we would ask patients these questions. In the current state, they were often afraid to ask questions because they weren’t sure if somebody said, ‘I need help with utilities payments,’ or prescriptions or housing, what to do about that. So they didn’t want to ask a question they couldn’t answer.

So they started creating that and they said, ‘What does a model look like?’ There’s a model out in San Diego called the Community Information Exchange that San Diego 211 runs and operates and has had great success with. And so they looked at trying to recreate some kind of version of that. They needed some partners to do that. They had worked with us. We had this resource database and they were looking at what piece of technology that could combine their resources with the screening tool. In the end, they selected IMPACT to be the lead agency to create kind of the rest of community as well as the technology piece. They selected this group called NowPow to do the technology.

In some ways, it’s starting like a community health exchange. But we’re actively recruiting partners because we want it to be a true community information exchange, with not just healthcare, but with all of the community-based organizations that health systems will be making referrals to – housing, food, utilities, all of those.

WHN: How does this work? 

JH: You’ve got the health systems, you’ve got those large social service and mental health systems that are all screening in the same way, asking a version of those same questions and providing the same referrals.

So I’m asking, ‘Hey, you’ve had hip surgery. You’re going home. Let me ask you a few questions about that. Do you have a place to go? Are you able to keep up on your mortgage or your rent? Is it a safe place for you? How about food? Are you able to afford that? Have you paid your utilities or are you behind? Do you have somebody else there with you who can help you manage your hip replacement?’ And if you say, ‘I need help with any one of those,’ it sends this message into the database and it pulls out and says, ‘Here’s a resource for that.’ So as a screener, I don’t have to be an expert in all community resources because the tool does it for me. And I can say, ‘Here you go, here’s a referral. I can print it out if you want it. I can text it to your phone. I can email it to you. And if it’s OK with you I would like to send this referral on to the agency that I’m handing you.’ And you say, ‘Yeah, that would be great.’ So I send the referral to the pantry that says, ‘We’re referring Scott. He’s going to be stopping by.’ And so they know that you’re coming. And then they’re enrolled in the program too. So that when you show up, they can say, ‘Yep, Scott made it to the pantry and received food for him and his family.’ And now as the healthcare provider, I have this new record of you and these things that you need and I can see I made these referrals and you either did or didn’t show up. It starts to create that.

And then you have these other community organizations participating in the same way. So now the food pantry may encounter you and you might say, ‘Oh yeah, this is great. But I’ve got this appointment that I have to get to next week and I just don’t have transportation.’ ‘Oh what? Wait a minute. Let me see if I can go set something up for you.’ So those community organizations can also do the screen and make referrals too.

What this does really is it creates this true community information exchange where it levels the playing field for all patients and all clients, so no matter where they enter the system, they get this screen and they can get these referrals. If you’re just talking about all the people out there that are encountering any of these systems and they have these needs, now it’s going to be really easy to do this screen, to get them the resource and it’s going to support all of those social determinants, those basic needs, and you can lift people to a point now where, ‘I can make sure that my kids go to school every day, I can check their homework, because I’m not spending every waking minute on housing, on food, on healthcare, all that stuff.’

And you have this set of community data because this information gets collected on every single person that gets screened – your gender, zip code, what was the service that you needed help with, where did you go for that. It’s got age, it’s got race, it’s got all of those things. So you can really take this data picture of the community and say, ‘This is what the people in our community are in need of, what they’re able to get to, what isn’t available in the community.’ And then the systems that can create change can say, ‘You know what? Based on this, we need more help with this resource here or we’ve got an excess of this resource.’ It just helps with the management of all of those resources.

WHN: When do you plan to launch? 

JH: It will be this summer sometime. It’s moved back a couple of months from what we thought it was a couple of months ago, unfortunately. But that’s just the way it works out. So we’re getting closer to that.

For the initial plan, we are working within Milwaukee County. All of the healthcare partners, their footprints go beyond Milwaukee County. So their plan is to extend this outside of Milwaukee. Our IMPACT footprint covers nine counties in southeastern Wisconsin. So we want to extend it into the nine counties. We’ve started conversation with folks in Waukesha County that are really interested. We’ve got something coming up in Washington County with people who are interested, Kenosha County. There’s a real appetite for this.

WHN: How will this help identify gaps in services?

JH: So we collect similar information from calls that we have. We took about 170,000 calls last year from people around these same set of questions and we collect enough information to know that one of the gaps is around housing. And anybody in the community would tell you that. It’s kind of a no-brainer. But we’re able to narrow it down and be a little more specific. Some of the other things we know are that not only housing but home furnishings are a gap. There are programs, and we participate in part of the housing in the community called coordinated entry. We can get people into an apartment. And then they walk in, like ‘OK, where’s the refrigerator and where’s the sofa and where’s the other stuff?’ And if it’s not furnished already, those resources are really scarce in the community. So we’ve been able to identify some of that.

I think what this will do is this will really amplify that as a set of data. There will be even more information and data there that will come from a wider range of people that are feeding into that data set. I think it gives another level of credibility to it, that people know this isn’t just IMPACT data, but this is data that’s coming from the health systems and the other community organizations that are feeding into this. So they may see it as a more complete set of data.

They’re certainly going to be more participants. This thing will have literally hundreds of thousands once it’s up and running, if you talk about how many patients Advocate Aurora would screen, how many patients would Froedtert, Children’s and Sixteenth screen. That data set is going to get even bigger.

This article first appeared in the Wisconsin Health News daily email newsletter. Sign up for your free trial here.