Impact in Action Video: DePaul’s 70% Closed-Loop Referral Rate
In April 2018, with funding from the UnitedHealthcare Foundation, the DePaul Community Health Centers (DCHC) partnered with Findhelp to begin its Care Fellowship initiative to address social determinants of health (SDoH). Findhelp supported DCHC in creating a coordinated approach that proactively identifies and fulfills the needs of its patients. Through this partnership, DCHC’s closed-loop referral rate has grown to 70% over three years.
How Findhelp meets DePaul Community Health Centers’ needs:
Screening & assessment feature allows DCHC’s navigators to easily identify and respond to patients’ social needs
Intuitive case management software keeps DCHC’s staff organized and informed of all patient activity
Our comprehensive network of social care programs makes it simple for DCHC’s staff to find relevant resources for their patients and close the loop on referrals
Challenges: Excel spreadsheets, complex needs, and follow-up
DCHC launched a community health worker program in 2011 to address its patients’ SDoH needs. The health care agency needed a way to manage all of its patient information, but did not have a reliable case management system or know of any software that would be useful.
DCHC’s community health navigators resorted to using Excel spreadsheets to keep its patient and client needs organized, but this was tedious to maintain, especially while trying to build trust with patients.
DePaul Community Health Centers (DCHC)
A member of Ascension, DCHC is a non-profit healthcare organization offering primary and preventive health services to all members of the Greater New Orleans community, regardless of their ability to pay. DCHC has provided access to high-quality, compassionate health care since 1834.
DCHC’s navigators stretch the boundaries of patient care. Their one-on-one support ranges from scheduling appointments and helping enroll individuals in health insurance, to home visits and more. While DCHC’s navigators are able to address some of these needs in real time, others are more difficult. They turned to Google to find local resources for patients, and although Google was helpful, their searches were extensive, time-consuming, and often not productive.
Furthermore, it was difficult to close the loop and confirm if help was provided. DCHC wanted an easy way to identify the needs of its clients and address their concerns while also staying organized internally so they could continue to complete their essential work.
How DCHC achieved a 70% closed-loop referral rate
In 2018, DCHC found and connected with Findhelp at a Medicaid conference. When the health care agency initially decided to partner with Findhelp, DCHC only wanted to use their custom platform to house patient information and did not consider the other case management tools Findhelp offered. Once DCHC saw the value of Findhelp’s comprehensive database of social services, however, its staff realized just how much their patients (and navigators) could benefit from the additional tools.
Shortly after the conference, DCHC launched its branded version of Findhelp’s search platform to support its Care Fellowship initiative. The goal was to connect patients and clients with organizations that address Social Determinants of Health, and effectively organize patient data, resources, and referrals. Utilizing Findhelp at the beginning stages of the initiative proved to be instrumental for DCHC and helped grow their closed-loop referral rate to 70%.
“We use Findhelp as a case management tool. It helps us keep our patients and clients very organized to remember what resources we sent them. So then we can see if one particular resource is in progress, if one is completed…it just helps keep us organized.”
Zwena Moore-Randolph
Director of Business Development and Community Engagement | DCHC
Dedicated navigation workflows
The community health navigators at DCHC have created dedicated workflows to monitor referral outcomes after referring their patients to a local community-based organization (CBO).
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Immediately after making a referral, the case manager updates the status to ‘pending’, to normalize the referral update process.
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Two days after the initial referral is sent, DCHC’s navigators follow-up with their patients to ensure they received help.
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If the patient has not yet received services, the navigators will reach out again two weeks later for another update.
In addition to specific follow-up timeframes, the navigators have also built personal relationships with many staff members at CBOs and encourage them to update the statuses of DCHC’s patient referrals. These workflows and relationships help navigators keep track of who is getting help and whose needs are still unmet to effectively manage the Care Fellowship initiative on their Findhelp platform, and close the loop on referrals.
Social needs screening
Beyond referrals, DCHC’s staff partnered with Findhelp to embed an SDoH assessment into its Findhelp platform. Findhelp’s assessment feature allows DCHC to collect and validate patient social care needs to provide navigation guidance for their staff.
After completing the assessment, patients automatically receive program recommendations based on their answers. They also have the option to receive their program recommendations via email, text, or print. The assessment feature makes searching for social services easier for DCHC’s patients while also giving insight to DCHC’s navigators on trends in their communities.
Results of Working with Findhelp
The Findhelp case management software offers DCHC’s community health navigators an easy way to find and save resources for their clients, assess their patients for social determinants of health, and stay organized and informed of all patient activity.
Through its Findhelp platform, strategic workflows, and the dedication of their community health navigators, DCHC closes the loop on referrals and gets individuals the help they need, sooner rather than later.
“What I find very helpful about Findhelp…this technology is geared toward what the patient needs. Findhelp gives you the resource, the contact information, the people who the agency serves, how to get in touch with the agency, and all of the information that the client needs to navigate that resource.”
Shelia Alexander
Community Health Navigator | DCHC
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