This page is part of the SDOH Clinical Care for Multiple Domains (v1.1.0: STU 2 Ballot 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 practitioner and referred to CP. CP refers to a CBO to deliver the service
Actors
- Practitioner (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)
- Patient takes standardized assessment tool to identify risks
- Health concerns identified include Food Insecurity and Transportation Insecurity
- Provider and patient determine that it is most important to address the Food Insecurity first – provider promotes the health concern to the problem list
- Provider and patient add a goal related to this problem to pursue enrollment in a SNAP program
- Provider and patient agree that the contracted CP should handle identifying a CBO that will provide a solution to the Food Insecurity problem
- 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
- Provider or Care Coordinator creates and sends an electronic referral (and a copy of the consent) to the CP
- CP receives and accepts referral
- 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
- CBO receives and accepts the referral
- CBO completes the evaluation and enrollment, updates the status of the referral to completed, and includes information on what was completed
- CP uses the input from the CBO to update the status of the referral and includes information on what was completed
- 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
- Practitioner
- Care Coordinator
- Patient
- Community Based Organization (CBO)
Provider Workflow (payer and CP workflow may be similar)
- Patient takes standardized assessment tool to identify risks
- Health concerns identified include Food Insecurity and Transportation Insecurity
- Provider and patient determine that it is most important to address the Food Insecurity first – provider promotes the health concern to the problem list
- Provider and patient add a goal related to this problem to pursue enrollment in a SNAP program
- Provider and patient agree that a referral to a contracted or non-contracted CBO is an appropriate next step
- 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)
- Provider or Care Coordinator creates and sends an electronic referral CBO
- CBO receives and accepts referral
- CBO completes the evaluation and enrollment, updates the status of the referral to completed, and includes information on what was completed
- 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)
Direct Referral Light
Note: same as Direct Referral with the following exceptions
Actors
- Community Based Organization (CBO) has an application that can interact with a FHIR API and does not have a FHIR server
Provider Workflow (payer and CP workflow may be similar) (same)
Provider – CBO workflow (payer and CP workflow are the same)
- CBO application queries Provider or Care Coordinator API for new or updated referrals.
- CBO finds new task and accepts referral
- CBO completes the evaluation and enrollment, updates the status of the referral to completed, and includes information on what was completed
- Provider 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)
Closing the loop with the patient
Note: applies to Providers, Payers and CPs as the referral originator
Patient assessed by provider and referred to CBO to deliver the service
Assumes patient is using a personal application (e.g., Smart Phone application) that has already been registered and authenticated with the provider’s EHR API and he CBO system API.
Actors
- Practitioner
- Care Coordinator
- Patient
- Community Based Organization (CBO)
Provider Workflow (payer and CP workflow may be similar)
- Provider establishes a Patient task that allows the patient to take and return a standardized assessment tool to identify risks via their application
- The assessment tool identifies Health concerns of Food Insecurity and Transportation Insecurity
- Patient and provider “meet” physically or virtually
- Provider and patient determine that it is most important to address the Food Insecurity first – provider promotes the health concern to the problem list
- Provider and patient add a goal related to this problem to pursue enrollment in a SNAP program
- Provider and patient agree that a referral to a contracted or non-contracted CBO is an appropriate next step
- Patient consents to be referred to the CBO and consents to have the information that will be provided sent to the CBO
- Patient does not want the CBO to call or send email – patient will contact the CBO directly
- Provider establishes Patient task that can be retrieved by the patient’s application – task includes contact information for the CBO
Provider – CBO workflow (payer and CP workflow are the same)
- Provider or Care Coordinator creates and sends an electronic referral CBO – referral instructs CBO to not contact patient
- CBO receives and accepts referral
- CBO establishes a task/questionnaire for patient to collect needed information
Patient - CBO workflow
- Patient application retrieves CBO questionnaire
- Patient completes and return questionnaire
- Patient uses contact information to contact the CBO
- CBO, based on the questionnaire response and patient call arranges enrolment in a SNAP program and provides the details to the patient
CBO - provider workflow
- CBO updates the status of the referral to completed, and includes information on what was completed
Patient - CBO workflow
- Provider establishes a completion questionnaire for patient to determine if referral was successful
- Patient application retrieves provider questionnaire
- Patient completes and return questionnaire
- Provider receives the questionnaire 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
- Patient may not have an appropriate application or completed process to register and authenticate with the API(s)
- Patient may not be willing or able to respond to the questionnaires