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Alliance FOR BETTER HEAL TH
+
Healthy Together Ri,,ferral Ni,,twork of Alliance for Bi,,trer He th
THE PROBLEM Service Providers are Fragmented
1. Healthcare and social service providers both lose visibility after their patients are discharged.
2. Co-occurring health & social needs are often under-addressed across the community
3. Vulnerable patients are seeking clinical care for social problems
PROPRIETARY & CONFIDENTIAL
Community
Government
Healthcare
Healthy Together Refe-rral Network of Alliance for Beue-r He-.alth
ltd UNITE us
80% of health happens outside of your four walls
Coordinating with Community Based Organizations (CBOs) is the solution to drive
outcomes
The key is ensuring CBOs are engaged and integrated into your patients’ overall care
PROPRIETARY & CONFIDENTIAL
Healthy Together Ri,,ferral Ni,,twork of Alliance for Bi,,trer He th
Inter-connecting healthcare & social services into one accountable coordinated ecosystem.
Empowering health systems & communities to work seamlessly together to impact every person’s health and social needs.
HEALTHY TOGETHER REFFERRAL NETWORK Outcome Focused Network + Software Addressing the Social Determinants of Health
PROPRIETARY & CONFIDENTIAL
Healthy Together Referral Network
Technology:
• Easy-to-use platform that tracks every step of the patient health journey inside and outside hospital walls.
Community Engagement: • Community engagement practice and process.
Partnership between Unite Us and Alliance for Better Health
PROPRIETARY & CONFIDENTIAL
Clowd CHes by Outcome for Employeflnent
~I , _ _____ _ - - -•--.. 1011...•- _..,l_ -
Closed Cases by Resolut>on ilnd Service Type
-- -
Healthy Together Ref en-al Network of A ll.lance for Better He,al1h
- --------- ._ ... ,_ , ... ,_ ... -.- - -c- --···- c.-.... --
---- ---=- . ..=... ,::::::.. ~-= ··- --- ·-·· -· ~--
• lru UNITE US
OUTCOME FOCUSED APPROACH COORDINATING ACROSS THE COMMUNITY AROUND EVERY PATIENT IN NEED
• Direct electronic referrals to best-fit provider(s)
• Track 100% of outcomes delivered by external partners
• Visibility into every patient’s total health journey
• Real-Time SDoH Outcomes & Performance Dashboard
PROPRIETARY & CONFIDENTIAL
= Dashboard Clients Reports My Networks Q I Sara Jones 9 I E] ® [ +
X
Jane Smith i--F+i4UiiiB3Uh·F AGE 35 I TEL 123-456-7890 I EMAIL [email protected] I ADDRESS 99 Main Street, New York, AK (
HOUSEHOLD 4 I HOUSEHOLD INCOME $32,000 I RACE Wh;te I ETHNICITY Non H;span;dLat;no
Records
SERVICE TYPE CR EATED"'
y Clothing Referral 8/31/2017
f: Employment Assistance
8/23/2017 Request
Food Case 8/15/2017
'1' Legal Case 7/23/2017
= Benefits Referral 7/15/2017
Forms
NAME
NC Serves Clothing Assessment
NC Serves Employment Assessment
NC Serves Food Assessment
Intake 1
NC Serves Housing Assessment
NC Serves Employment Assessment
Healthy Together Ref en -al Network of All.lance for Better He,al1h
Select
ASS I GNED TO STATUS
NC Serves Metrolina D Coordination Center
NC Serves Metrolina D Coordination Center
NC Food Bank • Iii -Housing Works • II -Single Shop • D
Select
UPDATE D
8/31/2017
Not Started
Not Started
7/25/2017
8/31/2017
Not Started
Timeline
JAN 1 6. 2018
9 Address Added by Ashl
;!I Employment Case Close
Resolution: Resolved Outcome: Employed Exit Date: 1/16/2018 Note: Client received Representative at Tar
I Note Added to Employ
Inte raction Type: Mee Date: 1/ 16/2018 Duration: 1 h Note: Initial appointm her resume. She will se
Employeement Referral
JAN 15. 2018
;!I Employment Case Creat
Orga nizat ion: Employ Description: Looking i working part time.
;!I Employment Referral He
Reason: Scheduling an
AWP Clothing & Housing Goods
WHO REFERRED THIS CLIENT TO AWP?
WHEN WAS THIS CLIENT REFERRED TO AWP?
WHAT NEEDS DOES CLIENT PRESEl'IT?
Select all that apply
IS CLIENT INTERESTED IN A CLOTHING
HAS CLIENT SOUGHT CLOTHING SERVICES FROM ANY ORGANIZATION IN THE COMMUNITY?
l(d UNITE US
FROM HELLO TO OUTCOME, YOU ARE CONNECTED AUTOMATED WORKFLOWS BETWEEN EXTERNAL PARTNERS AT SCALE
Configurable Screening: Patient and/or provider facing algorithmic screenings to stratify risk and identify specific co-occurring needs
Electronic Referral Management: Seamless referral workflow sends the right data to the right provider(s) to address specific needs
Assessment/Care Plan Management: Custom care plans for each service need that are attached to referrals so receiving providers get a head start
Bi-Directional Communication/Alerts: Automated notifications keep all organizations up to date, while care team members can securely communicate with each other
Outcomes: You get to know exactly what services were delivered, and the entire history for every intervention by your external partners
PROPRIETARY & CONFIDENTIAL
HEALTHY TOGETHER REFERRAL NETWORK INITIAL DATA AND FINDINGS
Efficiency has increased by ...
Average time in days to ..
4.69 52.09
1.78
5.04
... Intake and refer a client ... close a referral
■APR ■ MAY ■ JUN ■ JUL ■ AUG
Healthy Together Mi UNITE US Ref en-al Network of A ll.lance for Better He,al1h lW PROPRIETARY & CONFIDENTIAL
Healthy Together Refe.,ral Necwo,k of Alliance for Bene, Heal1h lru UNITE US
SUSTAINABILITY & SCALABILITY FOR THE LONG TERM WHAT’S NEXT?
NYServes Anti-Poverty Network Hillside BHCC
AHI PPS • Continue to grow & sustain Healthy Together Referral
Network
• Rollout internetwork referrals to neighboring networks to ensure no person falls through the cracks
• Goal is to create an accountable coordinated ecosystem of providers across regions, that are working together to address the multiple and complex needs of our most vulnerable populations. Healthy Together
Referral Network
PROPRIETARY & CONFIDENTIAL
Alliance FOR BETTER HEALTH
ltd UNITE us
THANK YOU!
+ Taylor Justice Keshana Owens-Cody President Director of Community Relations [email protected] [email protected]
