SDOH Clinical Care
1.1.0 - STU 2 ballot

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)
  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
  • Practitioner
  • 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)

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)
  1. CBO application queries Provider or Care Coordinator API for new or updated referrals.
  2. CBO finds new task 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 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)
  1. Provider establishes a Patient task that allows the patient to take and return a standardized assessment tool to identify risks via their application
  2. The assessment tool identifies Health concerns of Food Insecurity and Transportation Insecurity
  3. Patient and provider “meet” physically or virtually
  4. Provider and patient determine that it is most important to address the Food Insecurity first – provider promotes the health concern to the problem list
  5. Provider and patient add a goal related to this problem to pursue enrollment in a SNAP program
  6. Provider and patient agree that a referral to a contracted or non-contracted CBO is an appropriate next step
  7. Patient consents to be referred to the CBO and consents to have the information that will be provided sent to the CBO
  8. Patient does not want the CBO to call or send email – patient will contact the CBO directly
  9. 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)
  1. Provider or Care Coordinator creates and sends an electronic referral CBO – referral instructs CBO to not contact patient
  2. CBO receives and accepts referral
  3. CBO establishes a task/questionnaire for patient to collect needed information
Patient - CBO workflow
  1. Patient application retrieves CBO questionnaire
  2. Patient completes and return questionnaire
  3. Patient uses contact information to contact the CBO
  4. 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
  1. CBO updates the status of the referral to completed, and includes information on what was completed
Patient - CBO workflow
  1. Provider establishes a completion questionnaire for patient to determine if referral was successful
  2. Patient application retrieves provider questionnaire
  3. Patient completes and return questionnaire
  4. 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