Eliminating Inefficiency, Scaling Outcomes: How 51% of Bayhealth Patients Avoided Future Healthcare Utilization
Bayhealth, a leading healthcare system in Delaware, launched an effort to address non-medical drivers of health as part of its patient care model. Using Unite Us’ closed-loop referral system, Bayhealth has reduced ED readmissions, enhanced operational efficiency, and improved whole-person health outcomes.
Key Takeaways
Enhanced Data Visibility: Unite Us provides real-time data and reporting, enabling Bayhealth to track referral status and outcomes efficiently.
Improved Collaboration: Unite Us’ platform enables seamless integration with Bayhealth’s EHR system and its robust directory of community resources, streamlining the referral process.
Improved Health Outcomes: Preliminary analysis shows that 51% of patients with resolved cases did not experience any emergency department (ED) or inpatient (IP) utilization in the six months following case resolution.
Background
Bayhealth
is the largest healthcare system in central and southern Delaware, encompassing two hospitals, a freestanding emergency department, urgent care centers, and a variety of specialty physician practices. As a technologically advanced not-for-profit system with nearly 4,000 employees and a medical staff of more than 450 physicians and 200 advanced practice clinicians, Bayhealth is committed to delivering exceptional care. Affiliated with Penn Medicine for advanced specialties and a member of the Penn Cancer Network, Bayhealth serves a rural, diverse community with many non-clinical needs.
With a mission “to strengthen the health of our community, one life at a time,” Bayhealth recognizes that drivers of health (DOH) or non-medical needs play a critical role in patient outcomes. To strengthen the health of its community, Bayhealth began identifying and addressing DOH as part of its patient care model.
Challenge
Driven by its mission, Bayhealth was determined to meet the non-medical needs of its patients. However, before implementing Unite Us’ platform—which enables streamlined referrals and actionable data insights—the health system faced several key challenges:
- Screening Without Support: Bayhealth recognized the importance of screening for DOH and aimed to integrate it into routine care, identifying food insecurity as one of their patients’ top needs. However, many care team members were reluctant to screen for DOH needs, knowing they lacked tools and systems to adequately respond to identified needs.
- Fragmented Referral Process: The existing manual referral process was inefficient and inconsistent, often leading to delays and gaps in care.
- Limited Data and Reporting: Because Bayhealth lacked the infrastructure to generate meaningful reports or track outcomes related to its DOH efforts, measuring the impact of related interventions proved difficult.
“I had tried other software tools to conduct social care referrals in the past, but found them difficult to use. Not many of the organizations would actually receive referrals on the platform, which made it difficult to connect patients with resources,” Heather shared. There were also challenges with engaging community-based organizations (CBOs), resulting in a referral process that required extra steps and ongoing follow-ups. “It was just hard to find things, and it was always extra work or an extra step to get patients connected to resources.”
Heather Walker, RN, Population Health Coordinator at Bayhealth
Solution
In early 2022, after evaluating multiple vendors, the Bayhealth team selected Unite Us for its comprehensive, user-friendly platform that prioritized strong partnerships with CBOs and provided the tools needed for effective patient referrals and support.
With Unite Us, the Bayhealth team has been able to scale a comprehensive solution across the health system that includes:
- Robust, Searchable Directory of Community Resources: The intuitive platform allows Bayhealth team members to quickly connect patients with the right community resources to meet their needs.
- Seamless EHR Integration: Integration with Bayhealth’s EHR system has enabled staff to create referrals to community-based services directly from their EHR, streamlining the process and reducing administrative burden.
- Real-Time Data and Reporting: The Unite Us platform offers real-time updates on referral status and outcomes, allowing care teams to monitor and follow up on their patients’ care journeys. Detailed dashboards also offer Bayhealth real-time visibility into CBO engagement, allowing the team to track organizational activity and make more informed decisions at the point of care.
- Professional Services and Training: With ongoing training and support from the Unite Us team and access to Unite Us Learn on-demand courses, the Bayhealth team can continually refresh their platform skills, enhancing confidence, engagement, and comfort in navigating the technology.
“Other platforms don’t have the resources that Unite Us does. At my previous organization, the SDOH solution we used just didn’t have enough community-based organizations using the platform. Why would you create a referral that’s just going to sit there? With Unite Us, the difference in the organizations on the platform that actually interact and accept referrals is huge.”
Heather Walker, RN, Population Health Coordinator, Bayhealth
Impact
Since adopting Unite Us, Bayhealth has optimized its approach to community-centered care. By facilitating efficient connections with CBOs, Bayhealth has significantly reduced the time and effort spent on sending referrals, allowing care managers to focus on other priorities. The goal is that these improvements will translate to better long-term outcomes, with patients consistently connected to resources that address their non-medical needs.
- Improved Referral Acceptance Rates: Since using Unite Us, Bayhealth has seen an improvement in the number of CBOs engaging with and accepting referrals on the platform. Bayhealth can now group and send multiple referrals, enabling more reliable connections to resources.
- Enhanced Efficiency and Reduced Manual Workload: By eliminating the need for “phone tag” with CBOs, Bayhealth can now complete referrals with minimal extra steps. With a platform that seamlessly connects Bayhealth and CBOs, care teams can avoid time-consuming follow-up calls to verify patient information, creating a smoother experience for both patients and providers.
- Streamlined Closed-Loop Referral Process: Integration with Bayhealth’s EHR has made it easier for staff to create and track referrals, reducing the time and effort required.
- Data-Driven Decision-Making: By leveraging data and reporting capabilities, Bayhealth can better understand the non-medical needs of their patient population and make informed decisions to improve care.
Since implementing Unite Us, Bayhealth has measured the impact of case resolution on emergency department (ED) and inpatient (IP) utilization. Preliminary analysis shows that, on average, 51% of patients with resolved cases from August 2022 to January 2024 did not experience any ED or IP utilization during the six months following Unite Us case resolution. Case managers noticed that once a patient’s non-medical needs were met, those patients were less likely to return to the ED for non-emergency issues. They felt that patients were better equipped and more confident in managing their own health. This result highlights the value of integrating community-based care into healthcare delivery, not only to support patients with connection to vital resources in their communities, but to help prevent potentially avoidable ED visits and hospital admissions.
Lessons Learned
By partnering with Unite Us, Bayhealth has taken a significant step towards addressing their patients’ non-medical needs and improving patient outcomes at scale. Integrating the Unite Us platform with their EHR has streamlined the referral process, enhanced care coordination, and provided valuable insights through data and reporting. This partnership is a testament to Bayhealth’s commitment to providing comprehensive, patient-centered care.
- Technology Integration is Key for Efficiency: The seamless integration of Unite Us with Bayhealth’s EHR has been crucial in improving the efficiency and effectiveness of the referral process.
- Data Visibility Drives Continuous Improvement: Regularly reviewing and analyzing data and reports has allowed Bayhealth to refine their processes and interventions, enabling the health system to meet the evolving needs of its patients.
- Community Partnerships are a Cornerstone of Effective Care: Building strong relationships with community organizations is essential in providing patients the support they need.
“Unite Us has been a very helpful resource platform. I have been able to send referrals to multiple organizations for various patient needs. Some of my top referrals include the Food Bank of Delaware, Milton Food Pantry, Housing Alliance of Delaware, and organizations assisting with utility support. I am looking forward to continuing to connect with organizations through Unite Us and help my patients in the best way possible.”
Natalie Baker, Social Worker, Bayhealth
About Unite Us
Unite Us is the nation’s leading software company bringing sectors together to improve the health and well-being of communities. We drive the collaboration to identify, deliver, and pay for services that impact whole-person health. Through Unite Us’ national network and software, community-based organizations, government agencies, and healthcare organizations are all connected to better collaborate to meet the needs of the individuals in their communities.
