Provide Equitable Care for Under-served Patients
Anthony’s hemoglobin A1c is again hovering around 9 percent. Since no major incident has occurred, however, his persistent, poorly controlled diabetes has been noted, but not investigated. Without intervention, the patient will inevitably progress to a more serious event.
Discussions with Anthony reveal that he is not taking the medication because it is too expensive. He is referred to a community organization helping patients cover the cost of medicines.
While some health care providers have started collecting information on patients’ social and financial needs, the level of coded data for Social Determinants of Health (SDOH) is still low. Lacking also is the network of community resources that can assist providers in fulfilling the needs of patients with food and housing insecurity, transportation, and affordability of treatments. But the first task is discovery of the patients.
Roji collects and includes all coded SDOH information in patient databases. But we also offer a more immediate way of identifying patients for SDOH screening, using Roji Episodes and Analytics to evaluate the medical services provided to each patient.
Roji Health Intelligence patient episodes for diabetes help you to identify patients with persistent poor control. Understanding the root causes of persistent poor control ensure that you have actionable data to enable interventions.