SDOH Clinical Care
1.0.0 - STU 1

This page is part of the SDOH Clinical Care for Multiple Domains (v1.0.0: STU 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Functional Use Cases

Note: SDOH IG related Patient Stories are available on the Gravity Project Confluence site here

Indirect Referral

Note: applies to Providers and Payers as the referral originator

Patient is assessed by a caregiver and referred to CP. CP refers to a CBO to deliver the service

Actors
  • Caregiver (includes licensed providers and others that interact with the patient to assess social risk, set goal, and determine/recommend referrals)
  • Care Coordinator (coordinates the care and referral activities but normally does not make assessment, goal, or referral decisions)
  • Patient (consumer, client, etc.)
  • Coordination Platform (CP)
  • Community Based Organization (CBO)
Provider Workflow (payer workflow may be similar)
  1. Patient takes standardized assessment tool to identify risks
  2. Health concerns identified include Food Insecurity and Transportation Insecurity
  3. Provider and patient determine that it is most important to address the Food Insecurity first – provider promotes the health concern to the problem list
  4. Provider and patient add a goal related to this problem to pursue enrollment in a SNAP program
  5. Provider and patient agree that the contracted CP should handle identifying a CBO that will provide a solution to the Food Insecurity problem
  6. Patient consents to have the referral and its accompanying information (including the consent authorization) sent to the CP (which is a business associate of the provider’s organization)
Provider – CP – CBO workflow
  1. Provider or Care Coordinator creates and sends an electronic referral (and a copy of the consent) to the CP
  2. CP receives and accepts referral
  3. CP refers patient to a CBO, with which they have a relationship, that that can evaluate the patient’ eligibility for and help the patient enroll in a SNAP program, if appropriate
  4. CBO receives and accepts the referral
  5. CBO completes the evaluation and enrollment, updates the status of the referral to completed, and includes information on what was completed
  6. CP uses the input from the CBO to update the status of the referral and includes information on what was completed
  7. Provider receives the updated status and determines if the goal has been satisfied and/or progress has been made on the goal and updates the goal appropriately
Considerations
  • Will not always have contracted CP and therefore not a BA
  • CP may not always have a formal relationship with a CBO
  • Provider may have the relationship with the CBO
  • Provider may request to have the service delivered by a specific CBO
  • CP may need to split the request into multiple tasks to be performed by more than one CBO
  • CBO may not accept the referral or be unable to perform the requested service
  • Close loop via patient reported outcome (no electronic referral)

Direct Referral

Note: applies to Providers, Payers and CPs as the referral originator

Patient assessed by provider and referred to CBO to deliver the service

Actors
  • Caregiver
  • Care Coordinator
  • Patient
  • Community Based Organization (CBO)
Provider Workflow (payer and CP workflow may be similar)
  1. Patient takes standardized assessment tool to identify risks
  2. Health concerns identified include Food Insecurity and Transportation Insecurity
  3. Provider and patient determine that it is most important to address the Food Insecurity first – provider promotes the health concern to the problem list
  4. Provider and patient add a goal related to this problem to pursue enrollment in a SNAP program
  5. Provider and patient agree that a referral to a contracted or non-contracted CBO is an appropriate next step
  6. Patient consents to be referred to the CBO and consents to have the information that will be provided sent to the CBO
Provider – CBO workflow (payer and CP workflow are the same)
  1. Provider or Care Coordinator creates and sends an electronic referral CBO
  2. CBO receives and accepts referral
  3. CBO completes the evaluation and enrollment, updates the status of the referral to completed, and includes information on what was completed
  4. Provider receives the updated status and determines if the goal has been satisfied and/or progress has been made on the goal and updates the goal appropriately
Considerations
  • Will not always have contracted CBO and therefore not a BA
  • Provider may not always have the relationship with the CBO
  • CBO may not accept the referral or be unable to perform the requested service
  • Closing the loop via patient reported outcome (no electronic referral)