How BrainStream helps improve health equity

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

By Julie Santiago, Senior Vice President of Quality and Case Management at ilumed

As a registered nurse for more than 36 years, I had the unique opportunity to walk alongside patients during some of the most vulnerable times in their lives. Some patients had great resources and strong support systems, with families who care for them and ensure their needs are met. Other patients, however, faced their healthcare journeys alone, braving cancer and chemotherapy and working toward remission with healthcare providers like me as their only ally and confidant.

I’ve seen firsthand how social determinants of health such as food insecurity, loneliness and isolation, transportation barriers or other obstacles can impact what happens clinically with patients. Having to make choices between buying food and buying medicine, having an unsteady housing situation or not having access to reliable transportation can all play an important role in patients’ health outcomes.

At ilumed, our goal is to provide quality healthcare to all patients. We act as a nexus between the patient and the provider to help improve patients' outcomes and increase access to equitable healthcare in every community we serve. BrainStream, our proprietary patient data analytics platform, helps us pinpoint patients who might be struggling with these social determinants of health. The data generated by BrainStream can help providers as well as ilumed’s non-clinical support teams combat these social and economic challenges to achieve what healthcare providers refer to as health equity.

An in-depth look at BrainStream

To understand how BrainStream can help improve health equity for patients experiencing social determinants of health, it’s important to understand how the technology works.

Using industry knowledge accrued over decades of experience, our team created BrainStream to work in conjunction with electronic medical records, or EMRs, to calculate patient-risk scores and determine Medicare Risk Adjustment (MRA) scores and more.

The data harvested through BrainStream is then displayed in an easy-to-use, easy-to-read format alongside the data generated by providers' preferred EMR platforms, providing them with the information they need to make data-driven decisions that give patients the best possible health outcomes. By getting a comprehensive picture of a patient's health, providers are able to assess any potential risks associated with catastrophic events, social determinants of health or other complications.

In addition, ilumed's non-clinical support teams can access the data generated by BrainStream, connecting patients to a wide range of programs and resources. We take a multi-pronged approach to helping meet patients’ needs. We’ve partnered with organizations on both a local and national level to provide resources such as heat, nutritious meals and other essential items and services for patients in need until we can connect them to a community resource for the long term. The next-generation healthcare technology from BrainStream is the first building block in the bridge between providers and their patients because it helps them effectively manage their care between visits.

Driven by science, focused on people

So how can BrainStream’s data algorithms help us identify at-risk patients to further our goal of health equity? We’ve adopted the Accountable Health Communities (AHC) screening tool from the Centers for Medicare & Medicaid Services (CMS) to help us pinpoint patients who might be dealing with one or more social determinants of health. Through a series of questions answered by the patients themselves, providers and other non-clinical support staff can determine whether an individual might benefit from additional resources that could help them eliminate any barriers to better health. Using this objective and equitable process ensures that value-based care isn't provided subjectively, improves the provider's workflow and simplifies the process.

In addition to acting as a portal into the lives of their patients, technologies like BrainStream can also help providers examine what’s going on at the community level. Being able to spot healthcare trends within a specific area, such as a rise in diabetes or hypertension in a community with limited access to healthy food options, can help providers get to the root of the problem instead of treating the same conditions over and over.

Leveraging BrainStream empowers ilumed to help providers take a population-health approach to improving the overall health outcomes of patients in their communities. Our algorithms synthesize claims and clinical data, as well as an Area of Deprivation Index, socioeconomic and demographic info.

By analyzing all of this data together, we can create solutions tailored to those with the highest risk while providing both indirect and direct support. Our care management team reaches out to patients to help them schedule appointments, arrange transportation to and from their doctor visits, get food assistance and more. Using data generated by BrainStream, we help physicians get to the root of the problems that are standing between patients and better health outcomes.

Working together to achieve population health

A large part of being a healthcare provider is connecting with patients from a place of compassion and support to let them know that you’re there to help. Talking to patients about available community resources and outreach programs can help empower them to understand that they aren’t alone in their situation and that there are people on their side who can help them meet their needs. Our provider partners use BrainStream data to help start important conversations with patients in a way that preserves and upholds their dignity.

Since its inception, ilumed has set itself apart from other ACO REACH organizations by working at a community level to create solutions that drive population health. Our founder and CEO, Debra A. Finnel, was working to establish food banks within provider clinics even before health equity or social determinants of health were well-known terms. We see patients as people first and strive to help meet their individual needs with compassion and care. Once more, I have the privilege of walking alongside patients through their healthcare journey, just as I did throughout my nursing career.

I’m proud to be part of a healthcare organization that is, at its core, about people helping people. Contact us today to learn more about how you can join us in our efforts to achieve health equity for all.

Previous Article Next Article