Community-Based Care and Social Determinants of Health

The Massachusetts eHealth Collaborative (MAeHC) team understands the importance, pathways and sustainability needs for community-based care that takes into account the social determinants of health within an organization’s patient population.  The MAeHC team has two PCMH Certified Content Experts (CCE) and over ten years of experience working with practices to transform care to the Medical Home model of care.  Our work has been so expansive throughout New England and the nation, that our exposure to so many rural and urban populations has allowed us to build a toolbox of templates, trainings, processes, procedures, as well as a deep understanding of health technology available to assist organizations of any size or location meet their goals for incorporating social determinants of health (SDOH) into care plans and EHR documentation for sharing among all members of a patient’s care team, across the continuum of care.

MAeHC understands the barriers, limitations and complex needs of community-based care organizations and strives to provide aid that is sensitive to the social and cultural needs of the patient population of each client we engage.  We are acutely aware that social determinants of health, such as social, economic and environmental factors, play an integral role in developing tailored strategies that can lead to improved overall care and wellbeing of patients suffering from behavioral health conditions and social services issues. 

MAeHC has a demonstrated history working with organizations that provide community-based care and “wrap-around” services that sit outside of the traditional healthcare organization. Our Team has deployed technical assistance to support care coordination with hundreds of providers in Massachusetts and throughout the country.

Example Project:

MAeHC will assist with optimization and customization of EHRs, policy and process development, definition and monitoring of high-risk population for care management. This process will involve all staff levels to insure proper education, alignment and understanding of the processes to ensure effective team-based care, care planning, and tracking.

MAeHC will coordinate and cultivate relationships with Community Providers and service agencies to develop and educate care teams on closed-loop referral processes, implement and care management plan activities and documentation, and ensure consistent data and information flow between organizations. This may include the identification and selection of referral and care coordination platforms.