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Better Health Outcomes Through Innovation, Iteration, and Collaboration

Benjamin Franklin famously stated that “an ounce of prevention is worth a pound of cure.” Those words still ring true today, especially when applied to modern healthcare.

The unlikely link comes in what we now call the social drivers of health (SDOH) — factors like access to safe housing, healthy food, and transportation. Data shows that addressing these fundamental needs is an effective way to prevent and manage chronic health issues like obesity, diabetes, and asthma.

To that end, two members of KC Health Collaborative (KCHC), Children’s Mercy Kansas City and Blue Cross and Blue Shield of Kansas City (Blue KC), are working to connect patients with the social services they need to meet social needs that impact their health.

One step came a few years ago when Blue KC started asking providers to conduct SDOH screenings.

Children’s Mercy responded by systematizing what at that point was an ad hoc system of sticky notes, e-mails, and phone calls that served as a social-service referral system for families it was seeing through its network of community primary care practices.

Being more intentional about helping patients obtain nonclinical services demanded a new referral system, said Michelle Manaskie, assistant director of operations and population health management for Children’s Mercy.

“We as healthcare providers should not be asking questions of people that we can’t do anything about when they tell us that they have a problem or they need help,” she said

“If we just say, ‘OK, thanks for sharing,’ and we move on, it’s really quite unethical.”

Children’s Mercy staff started addressing the issue by directing families to resources listed by ZIP code on the national findhelp website — while also working on a locally branded version of findhelp’s social care technology.

Children’s Mercy named the local version Lift Up KC, which launched in March 2021. Since then, users have logged nearly 220,000 searches to make more than 21,000 connections with Kansas City-area social service providers.

Through Lift Up KC, Children’s Mercy has established referral partnerships with five community-based organizations (CBO) chosen specifically because each one offers a comprehensive range of assistance and because their combined service area covers a large part of the metropolitan area:

  • Bishop Sullivan

  • Community Assistance Council

  • Community Services League

  • El Centro

  • Metro Lutheran Ministry

A system like Lift Up KC requires a fair amount of troubleshooting, said Nikita Sharma, program manager of operations and population health management. “But it’s totally worth it to be able to see how many patients are able to get help … and hear that staff really appreciate being able to have this resource.”

Children’s Mercy physicians have embraced Lift Up KC.

One community primary care provider in a Medicaid practice praised the system in telling the Lift Up KC team that it only takes about 30 seconds to refer a patient through the electronic medical record software.

The mom of one patient also reported how relieved she was when a Children’s Mercy social worker secured shoes for the mom’s kids through Lift Up KC.

One hallmark of Lift Up KC is how the administrators have iterated through trouble spots while maintaining functionality for the users. Sharma gathers feedback through monthly meetings with the CBOs, collecting feedback and working collaboratively to identify and resolve issues.

In one slight change that made a big difference, Sharma had IT staff change a field in the referral form to reflect a parent or guardian as the point of contact for the CBO. The original version had the child’s name — because they were the patient — which caused some confusion when the CBOs made follow-up calls.

One of the biggest current challenges for Lift Up KC is figuring out how to increase the number of families that receive help after clinical referrals. CBOs have reported difficulty contacting some families and said several hundred households have told the organizations they are no longer interested in the services.

Manaskie said Children’s Mercy has avoided the pitfall of bogging down the system by looking to help every single patient right out of the gate. Their mindset is to improve each day as they help one family at a time.

“And we’re going to mess up and we’re going to fail,” she said, “but then you are going to learn from that failure and try to do it better the next time so that we can help more people.”

This is just the sort of innovative, patient-centered approach KCHC intends to bring to its efforts to address health equity in the region. Lift Up KC’s make-changes-as-you-go approach is the best way to turn data into action. Thinking slow and acting fast is a good axiom to live by in the health data world, and it’s a philosophy KCHC is working to embed within Kansas City’s health care ecosystem.


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