Care coordination technology helps a health network to address social determinants of health

Social determinants of health, which include access to food, transportation, housing, education, employment, etc are key to healthcare because, they often act as barriers that interfere with unmet physical and mental health needs.

Keshana Owens-Cody, director of community relations at Troy, New York-based Alliance for Better Health says that when people face challenges around social determinants of health or battle with physical or mental health needs, their priority shifts to making sure that their social determinants of health are met rather than physical or mental health needs.

She says, the system must assess and address these needs before the patient leaves an office just as symptoms of physical or mental health are treated.

The Alliance for Better Health has launched the Healthy Together Referral Network using technology from Unite Us. This is a community-wide network delivering integrated care that addresses social determinants of health of Medicaid beneficiaries in Albany, Fulton, Montgomery, Rensselaer, Saratoga and Schenectady counties.

To date the Healthy Together Referral Network has 53 participating organizations that work together to deliver more than 93 types of healthcare and social determinants of health services.

Organizations provide services ensuring basic needs (food, housing, utilities, etc) to physical, mental health services and self-management resources.