Dr James Whitfill on Assisting Patients With Social Needs

Scottsdale Health Partners helps patients with social needs through a complex care coordination program and working with community resources like adult protective services or other city government branches, James Whitfill, MD, chief medical officer, explained at the National Association of ACOs Spring 2016 Conference.

Transcript (modified)

How does the Scottsdale Health Partners ACO assist patients with social needs that could impact their health?

So I think probably 2-3 different areas that we really work to try to address a lot of those, whether you call them social determinants of health or personal barriers towards health: first of all we have a complex care coordination program that is, for the most part, staffed by medical assistants (MAs), we do have a few registered nurses in that. The MAs are pretty resourceful because they’re closer to that community, and they oftentimes are willing to think pretty unconventionally about what we need to do in order to solve a person’s issues. And so we will have 1-on-1 relationships between, say, a care coordinator and a patient.

At the same time we’re very involved in the city of Scottsdale and the community resources there, whether it’s the adult protective services, whether it’s the fire department, the paramedics—there’s oftentimes a lot of overlap between our higher risk patients and those that the community or the city government is trying to do outreach with.