211 service partners use inbound call centre technologies to deliver a referral process established to support anonymous service. As a result:
- Community Navigators can’t view client history.
- Organizations receiving referrals start from scratch.
- A holistic understanding of the client’s situation to determine interconnected needs is limited.
- The ability to support case coordination, goals, and prevention work is limited.
Community Connection’s Health Navigation team uses customized digital tools to improve data collection, streamline workflow, enable seamless client data sharing, and measure improved services for vulnerable people.
Our client database is a longitudinal record that supports trauma-informed practices, reducing the need for clients to explain their situation repeatedly. Navigators can view client history and status changes and collect detailed information that improves reporting. It is connected to the 211 network’s legacy systems, enabling full integration with our 211 call centre and specialty phone lines answered by our Community Navigators.
Integration with Ocean eReferral Network
Community Connection is an anchor partner in the South Georgian Bay Ontario Health Team and participates on the Digital Health and Innovation Action Team.
Dr. James Lane, the South Georgian Bay Ontario Health Team Digital Health Lead and Chief Medical Information Officer for Collingwood General and Marine Hospital, initiated an innovation project to support eReferrals through an electronic medical record directly into Community Connection’s client database and the status of these referrals directly into the patient’s chart.
For primary care providers participating in the Ocean Network, their patient's health records are updated on each referral and the referral outcomes. For community providers (paramedics, shelter services, addiction programs, etc.), eReferrals can be made from a web-based version available through the Ocean portal. Patients can also be kept updated on the status throughout this process if they can receive electronic communication. As a result of this project, Community Connection holds a provincial licensing agreement as a health information network provider.
Watch this short video (2:30 min) with Dr. Lane describing eReferral initiatives in a greeting to the Ontario College of Family Physicians conference.
Comprehensive Screening and Risk Rating Tool for SDoH
Community Connection has Canadianized an assessment tool developed by 211 San Diego that determines the immediacy of a client’s need along 14 domains and establishes a baseline risk to measure change over time.
The assessment walks individuals through a series of questions about 14 domains (housing stability, food security, activities of daily living, financial wellness, etc.). The questions help determine the immediacy of the client’s needs, their knowledge and utilization of services, and what social supports and barriers influence whether they are accessing these resources.
Each domain assessment results in a risk rating scale (In crisis, Critical, Vulnerable, Stable, Safe, Thriving). Each risk is aligned with Community Connection’s resource database taxonomy, improving the accuracy of identifying the most appropriate service provider. Further assessments during follow-up calls measure the client’s improvement or decline within the continuum.
The tool can be used as a foundation of shared language and measure around social determinants of health, for individuals and communities.