Alegis Care Care Associate, Tiffany, received an urgent call from the family member of a patient in our Chronic Care Management program. He had just returned from the store and discovered power had been turned off at the patient’s residence. This was especially concerning because the patient is homebound and confined to a hospital bed, which needs electricity to function.

Tiffany quickly took action, reassuring the family member. She immediately alerted the patient’s primary care provider to submit a medical criteria form to the utility company. Later that day, the family member let Tiffany know that power had been restored and the utility account was up to date.

Breaking down barriers

Examples like this are why the Alegis Care team set a goal to close 1,000 social determinants of health gaps in 2019.

Social determinants of health are factors in a patient’s physical and social environment that can have a significant impact on health outcomes. A gap exists if a specific factor - such as no electricity - hinders improved health outcomes.

Our providers have a unique opportunity to identify and help resolve gaps while caring for patients in their homes. They:

  • Observe and relay important information about a patient’s daily environment to the care team that an in-office provider might not know about, like caregiver support, access to food and transportation and even sense of physical safety.
  • Become a trusted, compassionate partner that patients and caregivers know they can contact for help resolving issues that impact a patient’s care plan.
  • Partner with social workers to determine the best strategy and solutions for common gaps.

The team worked towards achieving their pledge by screening patients during visits, connecting them with solutions to overcome barriers to care and following up to confirm that gaps in care were filled.

Tiffany, and the Alegis Care team, are helping to improve the health, well-being, and peace of mind of our patients and their caregivers – one care gap closure at a time.

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