Case Studies

Case Studies

Case Studies

Case Studies

Improving Population Health
Reducing Cost of Care
Enhancing the Patient Experience
Improving Provider Satisfaction
Engaging a Community
ENGAGING A COMMUNITY

Dignity Health: Engaging a Community With Tools and Support to Improve Health Equity

Overview

 

Dignity Health, a part of the nonprofit Catholic health system CommonSpirit Health, wanted to improve care access and health equity by enhancing collaboration and community outreach and addressing social determinants of health (SDOH).1,2

The Challenge

 

Dignity Health wanted to identify and address the needs of patients with respiratory diseases, including asthma and COPD, who are negatively affected by SDOH.2,3

The Approach

 

Dignity Health created the Total Health Roadmap pilot program, which integrated community health workers into family practices to address SDOH

  • Initiated standardized SDOH screeners2
  • Connected patients in need to appropriate community resources2
  • Coordinated care with social workers and health coaches1
 

A virtual health technology program provided patients with inhaler sensors for at-home monitoring3

  • Integrated digital platform and self-management tools into the EHR
  • Gave providers access to real-time data, alerts, and dashboards
  • Connected inhaler refill data to inhaler use data to identify and stratify risk

Outcomes

 

Total Health Roadmap pilot program (early results)1

  • Reduced needs in follow-up SDOH screeners
  • Reduced utilization of healthcare services
  • Increased confidence in managing health
 

Integrated virtual health technology pilot program (results at 1 year)3

  • 80% reduction in program enrollment time
  • 54% decrease in asthma-related ER visits
  • 57% decrease in asthma-related ER visits and hospitalizations, combined
 

COPD=chronic obstructive pulmonary disease; EHR=electronic health record; ER=emergency room.

 

1. Evans EM. How CommonSpirit’s primary care clinics are addressing social needs. The Playbook website.https://www.bettercareplaybook.org/_blog/2021/7/how-commonspirits-primary-care-clinics-are-addressing-social-needs. Published January 4, 2021. Accessed March 19, 2023. 2. Cole A, Stine N. Advancing patient-centered care: bringing social support into the fold. Catholic Health Association of the United States website. https://www.chausa.org/publications/health-progress/article/summer-2021/advancing-patient-centered-care-bringing-social-support-into-the-fold. Published Summer 2021. Accessed March 19, 2023. 3. CommonSpirit Health. Dignity Health and Propeller Health bring asthma and COPD digital inhaler data into EHR. CommonSpirit website. https://www.commonspirit.org/news-and-perspectives/news/dignity-health-and-propeller-health-bring-asthma-and-copd-digita#. Published October 5, 2021. Accessed March 19, 2023.