For this report, Simon Solutions surveyed 14 CharityTracker and Oasis Insight users whose primary focus was health to learn how our technology is helping them meet their mission and improve patient care. Please understand that some of the people mentioned in this report have changed jobs in their communities. Since the 2018 original drafting of this report, we have discovered an emerging trend in local community partnerships. Over 150 health care providers, across the country, use care networking technology to partner with charitable and human service organizations to do the following: improve community health, reduce duplication, streamline referrals, rapidly mobilize resources, and save millions of dollars in emergency room costs.
CharityTracker & Oasis Insight
Health Care Users Report 2020
Birthed out of a need for greater collaboration among social service providers in their own community, Simon Solutions technology out of Florence, AL has grown to service thousands of helping agencies in over 2,000 cities in 49 states. The number of new cities launching Care Networks has grown exponentially — about 250 per year. Now, cities in the United Kingdom, Australia, South America, and Africa are using this care networking technology.
The growth has not only been wide, but deep, uniting communities around holistic care including physical health and wellness as well as social services.
“Over the past five years we’ve seen a growing trend of healthcare agencies and hospitals using our technology,” says Mike Simon, co-founder of Simon Solutions. “The list of services provided from these various health organizations in collaboration with community agencies, churches, and schools is astounding. We are beyond excited to see our technology providing communication and referral services improving community health as well as helping hospitals and health clinics minimize readmissions through community resources.”
For this report, Simon Solutions surveyed 14 CharityTracker and Oasis Insight users whose primary focus was health to learn how our technology is helping them meet their mission and improve patient care. Please understand that some of the people mentioned in this report have changed jobs in their communities.
Since the 2018original drafting of this report, we have discovered an emerging trend in local community partnerships. Over 150 healthcare providers, across the country, use care networking technology to partner with charitable and human service organizations to do the following:
· Improve community health
· Reduce duplication
· Streamline referrals
· Rapidly mobilize resources
· Save millions in emergency room costs
We are amazed at how community-based organizations are partnering with hospitals and clinics to provide a better quality of life for individuals and families.
Health Providers Use Both CharityTracker & Oasis Insight
CharityTracker and Oasis Insight, two of the most widely used collaborative technology products of Simon Solutions, are very similar with one main difference. OasisInsight, a preferred solution for Feeding America, is designed for detailed tracking needed by food banks and food pantries while CharityTracker services a broader network of social service agencies. Interestingly, a recent survey of Hospitals, Clinics and Federally Qualified Health Center that use Simon Solutions’ collaborative software showed they are part of both types of networks.
Charles River Community Health (CRCH), whose mission is to is to improve the health and well-being of their surrounding communities, is a part of an Oasis Insight network administrated by the Greater Boston Food Bank. By using Oasis Insight for patient tracking and community resource networking, they are able to identify patients who are food insecure and refer them instantly. CRCH also partners with organizations tackling domestic violence, housing access, transportation, parenting programs, substance abuse, etc. CRCH offers a patient-centered medical home with medical, dental, vision, mental health, and pharmacy services. “In addition to offering primary care services and comprehensive care we offer many community programs to respond to the patient's needs,” says Francisca Guevara, Associate Director for CH and Outreach. Annually, CRCH serves 13,500 people.
Greater Boston Food Bank partners with additional health clinics in the region, some who provide a monthly produce distribution with seven varieties of fruits and vegetable for their patients, using Oasis Insight to register and check-in participants.
East Cooper Community Outreach is a part of a CharityTracker network administrated by Trident United Way in South Carolina. ECCO provides a free medical clinic, labs, prescription assistance, health education, as well as referrals to specialty care for the uninsured. Their health services division sees 500 people a year.
Health Providers Increasing Effectiveness& Saving Money through Community Networking
The Free Clinic of Franklin County, Inc. is a part of the CharityTracker network administrated by Carilion Clinic in Virginia. According to Executive Director, Donna M. Proctor, with CharityTracker “the online referrals expedite registration and enrollment. Bulletins and alerts help in getting assistance from other needs of patients.” As a nonprofit organization started solely with volunteers in 1992, today’s staff of six serves 900 patients a year, so efficiency and connectivity matter greatly. The clinic partners with Carilion Clinic, community health center, United Way, VA Cooperative Extension, and the Health Department to accomplish its mission.
Tyler Lee, Community Outreach &Development Manager for Carilion Franklin Memorial says that CharityTracker is helping them track free services through their clinic and network so that the hospital saves money. “We opened our network in November 2016. We have seen about a $1M savings and community benefit from this.” Where are those savings coming from? This network customized their database so that they can measure, and track the amount of services and hours given to patients in the free clinic. “Our free clinic charges’ patients—even though they never see the charges. CharityTracker allows us to track the hours and services given to the patient. For instance, the average cost is $123 per hour per sick visit including labs, blood draw, along with nurse and doctor time. We track that and if we look at the savings behind that—people going to the appropriate care setting instead of the emergency room, it is a win-win,” says Lee.
By networking as an entire community, Lee has seen some transformative outcomes for patients as well money saved for the hospital. “One story that really stands out to me comes from our local law enforcement using CharityTracker with us. One of our officers came into contact with an individual who was a chronic emergency room abuser and had a domestic violence situation at home. The individual ended up getting arrested. So now he is in the system and has a ton of medical debt. During the 30-day jail sentence, he had a wake-up call. The officer persuaded him to get help and signed him up on CharityTracker to connect him to that help. As a network, we were able to get him medical care at an FQHC and get him transportation there where he saw a doctor. They found out about his diabetes, which kept him visiting the emergency room. We were able to connect him to a care coordinator to manage his diabetes better, thus no more emergency room visits. Our network also connected him to a job fair. He now has a career in factory work, and everything is much better for him personally and for our community.”
The Martinsville-Henry County Coalition for Health and Wellness in Virginia is committed to providing medical and primary health services at its health centers and through a variety of other programs. Their goal is to promote health, reduce health risk factors and to increase access to medical services, primarily for the uninsured and underserved in their area. In what ways does using CharityTracker assist this Coalition in meeting its mission? According to Michael Farley, CEO, CharityTracker helps them “avoid duplication of services and client abuse.” Networking with agencies across the community means a wider distribution of resources for everyone. The Coalition serves as the CharityTracker network administrator, collaborating with United Way, Piedmont Community Services, Salvation Army, Goodwill, Grace Network, Ministerial Alliance, Harvest Foundation, VA Work Force, New College Institute and Patrick Henry Junior College.
East Cooper Community Outreach in South Carolina notes that being able to see where clients are seeking assistance is valuable in offering holistic care. Meredith Johnson, Health Services Manager, says, “Being able to see if a client is hopping from one clinic to another is helpful in encouraging a client to stick with one provider as a medical home. If we see a client is receiving utility assistance around the county, we are able to re-direct the client and possibly assist with job search or budgeting classes to help in reducing their expenses.”
Health Providers as Community Network Administrators
In many communities, healthcare systems are taking the lead on networking with community partners for the benefit of their patients, overall community health, as well as their bottom line.
Mission Health seeks to improve the health and lives of the people of western North Carolina, serving 900,000 patients annually through a wide array of professionals, volunteers, facilities, and partners.
According to Mission Health’s extensive 2017Annual Report, during the 2015 Community Health Needs Assessment, more than 70percent of key stakeholders across the region identified social determinants of health as a “major contributor” to local health issues. To improve these social determinants of health factors, Mission Health partners with churches, nonprofit organizations, and public health. According to Ashly Maag, Community Investment Manager for Mission Health, using CharityTracker to network together “helps to coordinate agency work and share information to create a stronger safety net.”
CHI St. Joseph’s Health System in Texas officially launched the Brazos Health Resource Center in October2016. The primary function of this center is to provide connectivity: community agencies connecting to one another and patients connecting to resources that help them live healthier, more stable lives. CHI St. Joseph’s Health chose CharityTracker technology to communicate, coordinate resources, share assistance records and make referrals.
According to center Director, Patricia Schoenemann, they offer CharityTracker technology and networking to service organizations in their community at no cost. “We also pre-load resource and community service information, making it immediately useful to organizations that join,” says Schoenemann. Along with CHI St. Joseph Regional Health Center, their CharityTracker network includes Society of St. Vincent de Paul, Salvation Army, Brazos Valley Community Action programs, and several churches.
Health Care Users Report 2020
“The churches that are in our network have been outstanding partners. They are so happy to work with us,” says Schoenemann. One the of most-used features of this network is the bulletin feature.
The Brazos Health Resource Center is able to inform their network partners of items people need, such as prescription assistance and medical equipment then Schoenemann and her team are able to round up the needed resources by connecting with community partners.
Texas A&M Rural and Community Health Institute, a network partner of the Brazos Health Resource Center, uses CharityTracker to assist them in providing community resource information for patients at their fingertips. According to Debbie Muesse, Program Manager for the institute, their mission is to improve health outcomes for diabetics in the community. Care coordination for the clinic’s 700patients is essential. [For a detailed account of how CHI St. Joseph Health and Brazos Health Resource Center chose CharityTracker as their collaborative technology solutions, built and customized their network, see the case study: Hospitals as Community Collaboratorshttp://www.simonsolutions.com/case-studies/hospitals-as-community-collaborators.]
OSF Sacred Heart Medical Center in Illinois also administrates a comprehensive community network using CharityTracker. Ashton Greer, Community Health Program Manager, says, “We serve others by making sure they get the help they need, even outside of the walls of our hospital.” After a community SWOT (Strength, Weakness, Opportunities and Threats) analysis for their county was complete, community leaders were brought together to talk about needs, problems and solutions for their community of Danville, IL.
Concurrently, the University of Illinois extension was doing a study in Danville about communication and how it is centralized or decentralized. “U of I was looking to see if collectively, we were doing a good job staying connected across the county as far as what resources there are, are we duplicating efforts and wisely staying in touch with other nonprofits. Basically, what came out of all of that was that there are a lot of help in Danville, but they don’t know what everyone else is doing,” says Greer.
Like most hospitals, OSF Sacred Heart Medical Center also faced a large number of re-admissions coming through the emergency department. “Our hospital had been wanting to create a network for quite some time so that we could reduce those re-admissions. Our emergency department is swamped. We have an entire department dedicated to reducing those readmissions. It is called Community Resource Center, and they help people get the social health that they need. A lot of times people come into the hospital for social health reasons, not physical health. We wanted to create a network so that when people come in, we don’t send them out empty-handed. We can connect them to a resource that they really need,” says Greer.
OSF Sacred Heart Medical Center launched a CharityTracker network in September 2017 with a small administrative panel with five organizations. Today, the network has grown to over 50organizations. While the health center does not use it clinically, they do use it to connect patients to resources. For instance, if someone calls the Community Resource Center needing transportation assistance to the health center, workers can utilize the network to quickly refer the patient to organizations offering bus passes.
The network includes many different kinds of nonprofit organizations and churches. In addition to helping thehospital connect patients to social service needs, churches are using it tocollaborate with one another and schools and community colleges use it to help their students. “School social workers use it to connect students to resourcesthey need to succeed and be well,” says Greer.
Health Providers Expand Patient Base through Community Networking
Health Partners, Inc. in Maryland is a non-profit primary care and dental clinic dedicated to providing compassionate care to the uninsured and underinsured of their community. They offer primary care for adults as well as a full range of dental care for adults and children. According to Ashley McMannis, Executive Assistant, Health Partners serves 2,000 patients annually with the following critical services:
· Breast Health Screenings and Cervical Cancer Screenings
· Connection to Care
· Information/Connection to other Community Agencies
· Medical Care and Referrals
· Follow Up for Chronic Conditions
· Adult and Pediatric Dental Care including Oral Exams, X-rays, Cleanings, Fillings, Simple Extractions, Root Canals and Crowns
By networking with organizations that provide housing and utilities assistance, clothing and food distribution, as well as churches and community centers, “Health Partners, Inc is able to extend our reach to populations who would otherwise not receive care,” says McMannis.
For this report, Simon Solutions connected with 14 different health-focused users, including Hospitals, Clinics, and Federally Qualified Health Centers. In addition to the interviews andinformation gathered, participants were asked to rank CharityTracker and OasisInsight.
Learn more from our over 800 customer reviews.
702 Customer Reviews of CharityTracker available at Capterra. Average rating is 4.5/5.
Hospitals as Community Collaborators
by Krista Petty, Community Connector, Simon Solutions
Hospitals and healthcare systems are moving into the community to collaborate with other organizations and churches for the benefit of their patients and overall community health, as well as their bottom line. CHI St. Joseph Health in Bryan, Texas is one such health system doing that. They are serving as a catalyst and anchor to community collaboration and collective impact, bringing a new level of coordination between the health system, local nonprofits, agencies and area churches.
In October of 2016, CHI St. Joseph’s Health officially launched the Brazos Health Resource Center. The primary function of this center is to provide connectivity: community agencies connecting to one another and patients connecting to resources that help them live healthier, more stable lives. One tool enhancing and measuring their success has been the implementation of CharityTracker, a cloud-based connective technology which allows organizations to seamlessly communicate, coordinate resources, share assistance records and make referrals for people in need of assistance.
While the mission of all hospitals is the physical and mental health of patients, research increasingly shows the strong correlation between physical and mental health with that of social, economic and environmental wellness. According the US Department of Health and Human Services and the Centers for Disease Control and Prevention, social, economic and environmental factors are actually more significant predictors of health than access to care.
This makes “your zip code more predictive of your health than your genetic code,” writes James S. Marks, former Assistant Surgeon General, Director of the Centers for Disease Control’s National Center for Chronic Disease Prevention and Health Promotion.
Hospitals and health systems involved in community and patient well-being beyond physical needs is called engaging in the “social determinants of health.” And while the social sector usually plays a primary role in meeting economic, social and environmental needs of families, because those determinants so greatly affect health, some health systems are taking a lead role in their communities, like CHI St. Joseph Health.
CHI St. Joseph Health’s mission is “to create healthier communities and nurture the healing ministry of the Church, supported by education and research.” “This often is expressed in the physical, psychological and spiritual healing of the sick, ”says Chaplain Mary Clare Carden, Director of Spiritual Care. To meet this mission more fully, the health system branched out to create the Brazos Health Resource Center.
Overcoming Obstacles to Optimum Health
The Brazos Health Resource Center is strategically housed in an area next to the Brazos Valley Council of Governments building, offering opportunities for collaboration. This area is home to some of the following agencies and organizations such as:
· Workforce Solutions
· Child Care Management Systems
· Housing Choice voucher program
· Area Agency on Aging
· ACA Marketplace
· County Indigent Care
· Affordable Housing
· Financial Fitness
· Project Unity
· Methodist Children’s Home- counseling for non-traditional parents
· Attorney General’s Office
· Brazos Valley Council on Alcohol and Substance Abuse
“We are in the middle of a large number of services for people who are already needing help. That was a beauty of being in this location,” says Pat Schoenemman, Director of Brazos Health Resource Center. Her two-person staff connects people to resources needed to improve their health.
According to Pat, the center acts as sort of a hub, helping clients and patients overcome a variety of obstacles. Pat shares the following example of their work: “In January, we got contacted by a lady who received our number from the homeless shelter. We found resources for her to go get her prescriptions. She was very well-educated and motivated but had a number of things working against her, including identity theft. She was working three jobs and was sleeping in her car.”
Working with other nonprofits and government housing agencies for quite some time, Pat was able to help guide her to more secure, safe and affordable housing. How did this impact her health? “She was told by her primary care physician that she would most likely not need to stay on her medication now that she was sleeping horizontally and not in the driver’s seat of her car, ”says Pat.
In their first year, the center helped over 570 families valued at over$57,000 of assistance, with virtually no budget for direct assistance of their own. According to Pat, the grant received to start the center was for employee costs and coordination in the community through technology. How are they resourcing clients and patients so well with very little budget? That’s the power of connectivity. “We promote resource coordination and communication, ”says Pat.
She attends a variety of community coalitions meetings, staying in touch with other social service resource providers and, as a 20-year veteran volunteer leader of the Society of St. Vincent DePaul, Pat is well connected. The center serves as network administrator for CharityTracker, the online shared community database and service directory. The technology is a tool used daily by the center and 60 other participating organizations and churches.
One of the most-used features of this shared database is the bulletin feature. Pat is able to inform local churches and agencies of items people need, such as prescription assistance and medical equipment. She is able to round up the needed resources by connecting. “The churches that are in our network have been outstanding partners. They are so happy to work with us, ”says Pat.
While demonstrating CharityTracker to a new church leader in their network, a bulletin popped up stating:
We just moved to a new office and we help with mental health in our community. We are looking for a source that might donate laptops. Can anyone give advice?
The pastor immediately told Pat, “Well, we can do that!” The church more than met that need with that organization and a new partnership and relationship was formed between those two groups.
“We know that for every fraction of a dollar spent on the social end, we are saving multiples of that dollar on the healthcare end. Reaching people who are chronically more ill because of poverty and stabilizing that part of their lives saves money and lives,” says Pat.
Where the Hospital/Community Collaboration Began
CHI St. Joseph Health first became aware of CharityTracker through the leadership of Mary Clare Carden, Chaplain and Director of Spiritual Care at CHI St. Joseph Health. “I had this vision of having a community center that people go to that would coordinate all of there sources, agencies, churches,” she says. She turned that vision into action, first creating a Faith Advisory Network. “I invited churches and agencies together in a meeting to talk about what they are doing. Once that took off, we needed to go to a more micro level, ”continues Mary Clare.
That micro level took them to starting CLARE Ministries (Community Linked to Access Resources and Education), named after St. Clare since at the time, before CHI, St. Joseph Health System was being operated by the Sylvania Franciscan Nuns in Sylvania, Ohio. CLARE Ministries included a weekly meeting of chaplains, social workers, case managers, and agency leaders, that could help with potentially challenging patients to discharge. “They were either homeless or needed help with medication, transportation to follow up appointments, etc.,” explains Mary Clare.
During this same time, the hospital was trying to identify the patients that were inappropriately using the emergency room for non-emergencies or even social needs, rather than physical. “It is known that 20% of the patients use80% of our charity care,” says Mary Clare. As part of the 1115 waiver, a pilot project began with these patients through community partnership, including Texas A & M University. Many times, patients were using the emergency room because of transportation issues, or not having a primary care physician, or inability to get a doctor’s appointments in low-income health clinics in a timely manner.
As part of this new project, the department responsible for the hospital’s accountable care organization hired care coordinators to follow a defined group of patients and a business arrangement was made with a local nonprofit clinic whereby the hospital could refer patients needing primary care access to appointments. “That was beautiful because they were able to get the min within a day or two to be seen by primary care doctor. If the patient needed transportation, they were given things like bus passes or even a taxi ride if they were outside of bus service to get to the appointment. The partnership even provided office space so that if people had mail order medicine and weren’t technically living in a defined address, they had a place to get their meds every month,” shares Mary Clare.
From the pilot project with the ACO, it was discovered that $5,000 in actual expenditures for the social services via the partnership saved the hospital emergency room an estimated $2 million in expenses, had those patients continued to use the emergency room, instead of the primary care physicians.
Initially, a spreadsheet tracked the social service assistance and Texas A&M University had its’ own program to track data. “But when we proved that assisting with the social determinants of health actually reduced emergency room visits and connecting patients to primary care physicians, that is when the need for Charity Tracker came in,” says Mary Clare. So, she back filled the data she had into CharityTracker to show how it would work for the community and the hospital.
“As a result of that data, we successfully applied for the one Episcopal Health Grant being awarded in the 57-county area. It was the largest grant our hospital had ever seen,” says Mary Clare. It is from this grant that the Brazos Health Resource Center was born, allowing Mary Clare to bring on Director, Pat Schoenemann, an office manager and two care coordinators and bring CharityTracker fully into the community for connectivity.
Meeting County Health Assessment Goals
While it’s hard to measure potential savings, the hospital is seeing by better meeting the social needs of their community and patients, the benefits of community connectivity are wide-reaching. In 2016, a community health assessment was done in the Bryan-College Station, Texas area. The findings led to several priorities that needed to be addressed in the community, and three that were focused on by the Brazos Health Resource Center:
· Access to primary care
· Mental health resources
· Communication and coordination of resources
Pat, who had recently been hired by the hospital to run Brazos Health Resource Center, walked into a meeting in December 2016. The partners were trying to figure out how to address the priority of communication and coordination of resources. Everyone from different community agencies was putting all their info together in a binder on pieces of paper. “When I walked in and told them about CharityTracker and it was free for the first 100 users because of the hospital grant, the look on that chairman’s face was ‘you saved me!’ Between our network and the 2-1-1 United Way referral network already operating with public access, we pretty much tied up the process and goal with a nice neat ribbon,” shares Pat. It became a mandate that everyone participating in the county health assessment process use CharityTracker.
Initially, when the hospital’s Faith Advisory and CLARE Ministries groups started looking into technology to support their collaborative work, they thought they would have to create their own system for case management. But with the hospital IT department already knee-deep in work with a hospital merger, Mary Clare was told their team would have to find something that was “already out there.”
“Someone had told me about CharityTracker, being used by Texas Food Banks and I followed up on the lead,” shares Mary Clare. After the first few demonstrations, she knew this system would meet the hospital and community’s need for connectivity, but there were HIPAA and legal requirements to get approved. “CharityTracker jumped all the hoops and the legal issues and became officially HIPAA compliant,” she says.
The developers at CharityTracker were open to Mary Clare’s vision and allowed her to make changes to the platform to fit her needs. The developers at CharityTracker also made it possible for Mary Clare to pre-load the information about nonprofit agencies, and churches, creating her own in-house service directory even before the network officially launched. “We did it backwards from the normal implementation, but it has worked!” she says.
In addition to the 60 agencies partnering to enter data and coordinate care with CharityTracker, there are 205 agencies with their 340 social services listed. This allows for organizations to see what is offered all across the community, referring even beyond the partners. “So, instead of turning people away when they need a service your agency doesn’t provide, you can better connect them to getting that need met,” says Pat.
Beyond Corporate Social Responsibility
While almost every hospital has philanthropic endeavors, the Brazos Health Resource Center of CHI St. Joseph Health System is going beyond filling a corporate social responsibility. The center plays a central role in connecting their community together for overall health and wellness.
They are modeling the inclusion and equity Norris and Howard wrote about in their article, Can Hospitals Heal America’s Communities? “Physicians, healthcare administrators, and hospital trustees face an important and historic leadership opportunity that our country and our communities desperately need.
For healthcare to both improve health and be more affordable, it must embrace a deep-seated concern for community, inclusion and equity as core to the business model, driving 100% of institutional capacity toward these aims.”
Regarding innovative approaches to community health, the Brazos Health Resource Center was featured in a 2019 research project conducted by the University of California at San Francisco. Their SIREN (Social Interventions Research & Evaluation Network)department was investigating innovative community resource referral platforms. SIREN featured this multi-county Care Network in Bryan, Texas in a webinar and also produced are source guide that featured CharityTracker technology.
SIREN Webinar: https://www.youtube.com/embed/4CGLSmqCChM
SIREN resource guide entitled, Community Resource Referral Platforms: A Guide for Health Care Organizations, San Francisco, CA: SIREN; 2019
Emerging Trends and Best Practices
The innovative ways that helping agencies, across a community, are using Simon Solutions care networking technology is often described as unprecedented and revolutionary. People, organizations, and institutions are learning how to align their unique strengths and collectively tackle tough community challenges(poverty, hunger, health disparities, and more) with greater impact and success.
Working together, they are better able to strengthen their social safety net, reduce duplication by as much as 91%, and create an effective referral system that “keeps individuals and families from falling through the cracks.”
Simon Solutions, Inc. (SSI) — Nationwide Impact
Number of Cities Using SSI Tools = 2,115
Number of People Served = 13 million
Number of Charitable Acts = 53 million
Community Dollars Contributed = $1 billion
Duplication Reduced as Much as = 91%
Average Annual Savings to Budgets = 18%
4Texas’ Medicaid 1115 waiver was based on California’s “Bridge to Reform” Waiver. The goal of the Texas waiver was to build health system capacity and to support innovations so that when more Texans gained health coverage in 2014 through both Medicaid Expansion and the new private insurance Marketplace, the health care system would be more efficient and better able to absorb new, formerly uninsured patients. Source: April2015 Fact Sheet: the Texas 1115 Waiver Renewal/Texas Coverage Gap Conversation by Anne Dunkelberg, The Center for Public Policy Priorities
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www.oasisinsight.net (preferred solution for Feeding America)