DePaul Community Health Centers Has a 70% Closed-Loop Referral Rate After Partnering with Aunt Bertha

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In April 2018, with funding from the UnitedHealthcare Foundation, the DePaul Community Health Centers (DCHC) partnered with Aunt Bertha to begin its Care Fellowship initiative to address social determinants of health. Aunt Bertha supported DCHC in creating a coordinated approach that proactively identifies and fulfills the needs of its patients. Through this partnership, DCHC’s closed-loop referral rate has grown to 70% in the three years since its staff first adopted its whitelabel version of Aunt Bertha’s search platform.

How Aunt Bertha Meets DePaul Community Health Centers’ Needs:

  • Aunt Bertha’s assessment feature allows DCHC’s patients to easily connect with the social services they need;
  • Aunt Bertha’s easy-to-use case management software keeps DCHC’s staff organized and informed of all patient activity;
  • Aunt Bertha’s comprehensive database of social care programs has made it simple for DCHC’s staff to find relevant resources for their patients.

About DePaul Community Health Centers

DePaul Community Health Centers (DCHC), a member of Ascension, one of the leading non-profit and Catholic health systems in the U.S., is a non-profit healthcare organization offering primary and preventive health services to all members of the Greater New Orleans community, regardless of their ability to pay. DCHC has provided access to high-quality, compassionate health care since 1834.

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Challenges

DCHC launched a community health worker program in 2011 to address its patients’ SDoH needs. The health care agency needed a way to manage all of its patient information, but did not have a reliable case management system or know of any software that would be useful. DCHC’s community health navigators resorted to using Excel spreadsheets to keep its patient and client needs organized, but this was tedious to maintain, especially while trying to build trust with patients.

Bryan Refsland, a community health navigator with DePaul Community Health Centers, delivers a box of food to one of his clients in New Orleans, LA. Refsland works primarily with a population of formerly homeless individuals, helping them navigate the social services they need to maintain healthier lives.

DCHC’s navigators stretch the boundaries of patient care. Their one-on-one support ranges from scheduling appointments and helping enroll individuals in health insurance, to home visits and more. While DCHC’s navigators are able to address some of these needs in real time, others are more difficult. They turned to Google to find local resources for patients, and although Google was helpful, their searches were extensive, time-consuming, and often not productive. DCHC wanted an easy way to identify the needs of its clients and address their concerns while also staying organized internally so they could continue to complete their essential work.

How DePaul Community Health Centers Increased its Closed-Loop Referral Rate 

In 2018, DCHC found and connected with Aunt Bertha at a Medicaid Conference. When the health care agency initially decided to partner with Aunt Bertha, DCHC only wanted to use their custom platform to house patient information and did not consider the other case management tools Aunt Bertha offered. Once DCHC saw the value of Aunt Bertha’s comprehensive database of social services, however, its staff realized just how much their patients (and navigators) could benefit from the additional tools.

Shortly after the conference, DCHC launched its whitelabel version of Aunt Bertha’s search platform to support its Care Fellowship initiative. The goal was to connect patients and clients with organizations that address Social Determinants of Health, and effectively organize patient data, resources, and referrals. Utilizing Aunt Bertha at the beginning stages of the initiative proved to be instrumental for DCHC and helped grow closed-loop referral rates to 70%.

We use Aunt Bertha as a case management tool. It helps us keep our patients and clients very organized to remember what resources we sent them,” says Zwena Moore-Randolph, Director of Business Development and Community Engagement, “So then we can see if one particular resource is in progress, if one is completed…it just helps keep us organized.

DePaul Community Health Centers’ team of community health navigators has grown to include 12 navigators, some of whom are pictured here in their office in New Orleans, LA. The navigators spend a lot of time away from their desks, helping community members access the social services they need to improve their health.

The community health navigators at DCHC have created dedicated workflows to monitor referral outcomes after referring their patients to a local Community-Based Organization (CBO). Immediately after making a referral, the case manager updates the status to ‘pending’, to normalize the referral update process. Two days after the initial referral is sent, DCHC’s navigators follow-up with their patients to ensure they received help. If the patient has not yet received services, the navigators will reach out again two weeks later for another update. In addition to specific follow-up timeframes, the navigators have also built personal relationships with many staff members at CBOs and encourage them to update the statuses of DCHC’s patient referrals. These workflows and relationships help navigators keep track of who is getting help and whose needs are still unmet to effectively manage the Care Fellowship initiative on their Aunt Bertha platform.

Beyond referrals, DCHC’s staff partnered with Aunt Bertha to embed a social determinants of health assessment into its Aunt Bertha platform. Aunt Bertha’s assessment feature allows DCHC to collect and validate patient social care needs to improve navigation of their whitelabeled platform and provide guidance for their navigators. After completing the assessment, patients automatically receive program recommendations based on their answers. They also have the option of getting their program recommendations sent to them via email, text, or print for ease of use. The assessment feature makes searching for social services easier for DCHC’s patients while also giving insight to DCHC’s navigators on how to better serve their clients.

Results of Working with Aunt Bertha

What I find very helpful about Aunt Bertha…this technology is geared toward what the patient needs,” says Shelia Alexander, Community Health Navigator,Aunt Bertha gives you the resource, the contact information, the people who the agency serves, how to get in touch with the agency, and all of the information that the client needs to navigate that resource.”

The Aunt Bertha case management software offers DCHC’s community health navigators an easy way to find and save resources for their clients, assess their patients for social determinants of health, and stay organized and informed of all patient activity. Through its Aunt Bertha platform, strategic workflows, and the dedication of their community health navigators, DCHC closes the loop and gets individuals the help they need, sooner rather than later.


Want to learn more?

Read about how your organization can benefit from the Aunt Bertha network and check out our new video above on the DePaul Community Health Centers.

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