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Closing the Loops of Warm Hand-offs Using Social Intelligence and Improved Information Systems


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For nearly ten years, Stakeholder Health partners have helped each other be smarter and braver, linking our most mature values with our most relevant science. Sometimes we feel so far ahead of our traditional clinical systems that we feel like strangers in our own systems. And then come times when all the systems are utterly overwhelmed, uncertain and afraid.

In February we gathered on the other side of King County (WA) from the elder care facility that riveted the attention and broke the hearts of the nation as COVID-19 came home.  We could see the old normal healthcare world evaporating by the minute, taking all its protocols, payment models and IT that are so disconnected from social reality. We left our hotel where we had worked for two days without knowing quite how much had changed.

Just than a month later, we still can’t see the new normal. But those of us in Stakeholder will probably recognize it as we have long imagined: our healthcare organizations focused on the humble service of mercy and justice, with seamless integration of the bio-medical, psychological, social and spiritual.

That is the ancient normal that still resonates in our bones. But we couldn’t figure out how to clear away all the modern clutter. Now, perhaps, we may find ourselves building Next Normal equipped with the very best of science and information systems. The moment we thought was long over the horizon may be at our fingertips, on our keyboards, emerging from our IT meetings and Zoom calls…now.


Executive Summary


“The integration of socioeconomic and environmental risk into the EHR is an important aspect of improving community and patient health, and achieving health equity.”

This document summarizes a February 2020 meeting of Stakeholder Health partners who gathered to discuss the crucial need for the integration of place-based social information into health systems’ Information Technology systems.

Key takeaways included the need for a common language around population and community health, and the need for “people” to close the loop between technology referrals and community resources. The group made recommendations for key internal discussions with the health system C-Suite, including a credible argument for the link between mission and technology.

Participants also outlined current IT practices, noting that some systems use multiple IT systems and that among them, there are 29 external platforms for community resources. The document also includes a description of promising practices, a “wish list” for the ideal technology, and recommended next steps.

Using Social Intelligence & Improved Information Systems