Social services’ ability to identify and connect people to health care services is another important aspect to the social determinants of health movement, says Kimberly Delp RN, BSN, Senior Director of Home & Community Based Services at Northern Area Companies/ Landmark Home Healthcare Inc. She manages the lead agency for Meals on Wheels Greater Pittsburgh.
Pittsburgh’s Meals on Wheels Chapter has written the specifications and utilizes a mobile app that connects those in need to medical professionals. This enables seniors to maintain independence, remain in their own homes, and prevent avoidable hospitalizations, ER visits and lengthy nursing home admissions.
“We didn’t want to be just about the food,” Delp says. “We wanted to be the eyes and ears of those homebound folks. We wanted to be a part of the overall strategy to reduce healthcare costs.”
Here is how it works: When volunteers delivering food notice that a homebound client may need medical attention, they press the “Change in Condition” button on their smart phone app as a Health Care Status change. This alert goes to the Intervention Specialist, RN, who follows up with the client to facilitate medical attention in a timely manner.
In one example, Delp states a meal delivery person noticed one of his regular clients was not walking as he had been in prior visits. The driver used the app to place the “Change in Condition” alert to the Intervention Specialist. The RN followed up with both the family member and consumer to facilitate timely medical care. In this case, the man was found to have a fractured hip, received the needed medical care and was able to return to his own home.