Key Takeaways

Jessica Beckwith, MPH
Vice President of Clinical Programs

The Commonwealth Fund recently published an update of its Guide to Evidence for Health-Related Social Needs Interventions.  It’s a fascinating and comprehensive review of existing evidence on the impact of interventions on health in housing, home modifications, nutrition, transportation, care management, counseling, and social isolation, and loneliness.

Among the results that stood out to me was from a subset of studies that compared Permanent Supportive Housing (PSH) with a control group. In the PSH group, ED visit rates were 14% to 54% lower; hospital admission rates were 29% to 43% lower; hospital days were 29% to 43% lower, and total health care costs were $245 to $1,940PMPM lower.  Some studies also found increases in outpatient utilization of care, suggesting better access in the PSH group.

As we continue to think about reducing healthcare costs and improving access, social determinants of healthcare are a critical piece of the puzzle that we must work to address!  

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Matt Troup, PA-C
Medical Director

A hospital admission can be a significant moment in a person’s life.

As members of a patient’s care team, we go to great lengths to ensure patients are set up for success at the time of discharge. Medication lists are updated, prescriptions sent, follow-up appointments made, and discharge instructions are completed and translated into verbiage patients understand. But even with the best intentions, the movement from the hospital to home is still a period of significant vulnerability. All of this preparation can unravel quickly when met with a patient’s re-entry into their daily life, not to mention the multiple barriers to care that exist as soon as they step out of the hospital.

My work at Memora Health has motivated me to lean even further into this vulnerable period, to seek out opportunities where improved communication can reinforce post-discharge plans. Recently, a cohort study was published examining how a post-discharge, text message-based program impacted readmission rates. This study showed that an “automated system of monitoring patients after hospitalization was associated with a 41% reduction in the odds of 30-day use of acute care resources, suggesting that a 30-day automated texting program can improve post-discharge outcomes among primary care patients."

Being proactive with communication after discharge, moving “upstream” to anticipate the needs of patients that might arise, and providing on-demand support during a vulnerable period in a patient’s journey has significant value to both patients and their care teams. There’s a lot more work to be done, but it’s great to see research that supports the need for increased communication with patients.

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Caleb Johnston, RN, MBA Oncology Clinical Programs Manager

Can customized clinical decision support (CDS) tools that provide clinicians with information about patient life challenges improve patient outcomes by helping clinicians contextualize their care?

A really interesting way of conceptualizing what we so often do in health care without even realizing it. We use context to support and guide clinical decision making.

This works well in the inpatient setting, where there is so much context to pull from, but is there a good way to get relevant clinical context for patients outside the walls of a hospital? Would additional context help make better decisions and improve care?

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Lorissa Snaith, BSN, BPHE, RN
Women’s Health Clinical Program Manager

In honor of Menopause Awareness Month, I attended stimulating webinars that sparked many great discussions about what every female everywhere will experience–menopause. It's a dynamic shift that aging females go through, and there are clear gaps in how current support is offered.

The good news is that technology-first solutions are on the rise that will support women throughout their menopause journey. I was most intrigued by this space’s market data, research, and innovation. Biotech is making leaps and bounds in the space of symptom management and ovarian longevity with the use of hormones. And new products are on the rise with personal hygiene (pads), skin care (dry skin), and supplements (vitamins). There is much more development needed; this is just the beginning.

Women worldwide are reclaiming their spaces and voices by publicly discussing the topic of menopause, but we still have a lot of work to do to minimize care gaps related to menopause care journeys. It was stated that 1 in 5 women who seek medical attention for symptoms related to menopause walk away untreated and are left feeling miserable. We need to educate and innovate new ways to bring easy digital access to menopause healthcare guidance, so more females know how to manage their symptoms and are aware of what options are available to them. More conversations (like the ones for awareness month) and more research will only help bring resolution to this arena where massive opportunities to enhance care exist.

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