The Aunt Bertha Blog

Why do hospitals struggle to manage social needs of patients?

At Aunt Bertha, we continually are on the lookout to understand what does and does not work when it comes to helping people in need connect with social services, which led us to conduct a survey of hospital executives through our partnership with GLG Social Impact. The survey assessed hospital executive’s perspectives on the role that community-based social services play in supporting their missions and their capacity to connect and track when these services are received.  The survey shows that 95% of hospitals face difficulties with tracking and measuring utilization of referrals to social need-based agencies and 60% of hospitals do not have a solid tracking method in place.

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Perspectives on Social Needs in Communities

The need for help is not limited to the income level of the patient.  While all hospitals had patients in need, more than 20% of population needs additional support at 63% of the hospitals studied. When hospital executives were asked how they would describe a patient population that needs social help,  the reasons went far beyond income.  A lack of caregivers at home, an aging population, a lack of support once a patient leaves the hospital, and a lack of knowledge of services available to help were all cited.  Each patient population has a unique combination of needs that a hospital has to serve and monitor.



Why does a systematic approach to connecting patients with social resources matter?

Hospitals are facing increasing pressure to focus on long-term clinical outcomes as quality measurement, pay-for-performance and other value-based purchasing strategies become the norm. In particular, the readmission penalties being applied by Medicare create substantial incentives for hospitals to take a more holistic view of the patient upon discharge, including addressing the social determinants of health.

The focus on addressing the social determinants of health is growing, and is expected to become increasingly important over the next 5 years.  The survey showed that 94% of respondents indicated it is important or very important to connect patients with social programs.  Respondents also closely align connecting patients with social resources to their organizational goals. 50% of respondents indicated improvements in this area will be critical to their long term success and another 33% indicated that they will become more important. However, as the survey indicates, most hospitals do not have a systematic process for making these connections and little is being tracked.

The time spent finding resources matters as well for a busy care management team.  A recent McKinsey study showed that employees spend an average of 9.3 hours per week looking for information. Until recently there were no consistent and systematic methods for hospitals to find community-based social service programs and track patient referrals to these programs, which leads to a resource burden.

Where does the difficulty in implementing a systematic approach and tracking lie?

Approaches implemented in the past by hospitals to address the social needs of their patients were informal and unstructured.  Respondents indicated that the most common methods for identifying social services agencies were information maintained on personal lists and Google searches.

Despite significant awareness of patient needs for social supports by hospital executives, more than 70% of respondents indicated that they either had a process for making referrals to social service agencies that was not systematic or that they had a systematic process that was underutilized.  About 60% of respondents indicated that utilization of referrals to social services was either not tracked and measured at all, or was tracked poorly and in a decentralized fashion.  An even higher percentage (about 65%) gave the same responses with respect to the tracking of outcomes from referrals to social services.

The most common explanation for not providing more navigation services to social programs was that it takes too much staff resources.  In addition, more than half of respondents identified the lack of software or a tool to find resources as the primary reason for not having a more systematic approach to tracking social needs support.

Best practices for Social Need referrals and outcomes 

Hospital executives recognize the need to address the social needs of their patients but are not doing so in a systematic way because they lack the tools and the data they need to support their efforts.  There are great advances in these capabilities, and the following best practices should be in place as part of any systematic approach for making referrals and tracking outcomes:

  1. Have a centralized system that makes it easy to find social program resources 
    Care management teams are extremely busy, so any new solutions must be easy to use and save time or there will be challenges with user adoption.  Making sure a solution is easy to use will not only promote adoption among a care team but also allow more staff members, such as front desk staff at a provider’s office, to help navigate patients to resources as well.
  2. Make sure program data is up to date and accurate.  
    A social program database must have depth of agency listings and be up to date and accurate.  This will also promote adoption and usage of the solution and avoid situations where trust is lost with the patient if a referral is made with inaccurate information.  
  3. Empower patients to self navigate 
    There will be times when a patient has a new social need that happens when they are not engaged with a staff member.  There may also be sensitive needs with relation to human service needs that patients are not comfortable sharing with hospital staff.   Empowering patients to self navigate solves these challenges and still allows for information to be collected on human service needs.
  4. Collaborate with the social program agencies you are referring patients to 
    Nonprofit and government human service agencies have their own missions and goals, many of which align with the missions and goals of hospitals.  Both have missions that center on helping people in need to achieve better outcomes.  Collaborating with local agencies to refer patients into can help in meeting patient’s humans service needs and in some cases help with referrals tracking.
  5. Create reporting that shows which referral activities are impacting outcomes.
    A centralized human service referral system can provide a wealth of data that includes specific areas of human service needs for your patient population, which agencies are being referred most often and how many times they were able to provide help, and which employees are regularly making referrals.  Tieing this information to patient health data can show which human service activities are having the greatest impact, guiding best practices for staff members.  

How can Aunt Bertha help?



Extensive, easy-to-navigate data

Aunt Bertha's software for hospitals and health plans helps to more effectively and efficiently connect patients to agencies that assist with food, housing, transportation, and other services.  This provides a quick and consistent process for social program referrals.  

The interface is also easily used by patients who are ready to self-navigate the process.


data-dashboards-600.pngReporting and collaboration capabilities

All activity is recorded so referrals and areas of greatest need for a patient population can be seen in real time in our analytics dashboard, allowing executives to spot trends, analyze gaps and determine which social interventions have the greatest impact.  




Download Study and Best Practices Request a demo ›

Topics: reporting analytics social determinants of health

Population Health Reporting

Organizations taking a vested interest in population health face a handful of challenges when it comes to identifying the social service needs of their members and/or patients. Historically, it has taken a considerable amount of work to find and organize domestic programs in the United States. Until now, the information on these services has either been scattered or siloed. Aunt Bertha aggregates domestic free and subsidized programs that are direct service from respective county, state, and federal levels.

Whether you are a local nonprofit or a multi-billion dollar health care organization, teams must confront the difficulty of better understanding the social services offered in their local communities, and their patient's respective needs. The inability to do so, can result in a multitude of negative consequences; ranging from expensive readmissions costs to missing the root cause of a member’s problem altogether.

If you are an agency providing a social program, you may understand the demand for your specific offerings, and respective capacity to perform these services. This is helpful, but do you know the number of individuals searching for programs similar to yours in your county? How about how many are searching last week or today?

Currently, most organizations are making anecdotal assumptions about their comminity's needs - or using academic reports that are out-dated. Are you scrambling every time a grant is due? Are you walking around with a pen and pad asking your employees how many people they served last year? In the past, the technology and systems simply haven’t been in place to understand these patient/member communities.

In real-time, Aunt Bertha tracks data related to the demand for specific social programs and the number of resources available to meet those demands. Our inventory reporting helps you clearly understand the current organizations offering programs by geographic location. Nationally, we have a plethora of programs across thousands of domestic providers. 

 Social Service Programs Across the US

Image: Aunt Bertha's customers can see - in real-time - the number of programs of all types in their community through an interactive reporting dashboard powered by Tableau, a world leader in reporting and data visualization software.

Additionally, our data team keeps the information up-to-date, and is constantly sourcing more information. With Aunt Bertha’s data and analytic tools, organizations can better understand the specific social needs of the population they serve and gaps that may exist in the system causing those needs to go unmet. 

However, there’s something even more interesting that our customers are seeing.

What if you could truly understand the needs in your community - in real-time? What if you could see reports that show you the exact number of people looking for food in the neighborhoods you serve? Or what if you provide subsidized dental services and you wanted to know which neighborhoods need the help? 

We believe this kind of data can lead to insights which can change the way social services are found and delivered - and ultimately - improve health outcomes in your community.

There are innovative, forward thinking organizations already looking at their own data to help people get healthier. And we’ve gotten to know some of them. For example, a healthcare system in Baltimore realized that some of their patients just needed a ride to their appointment. If someone who leaves a hospital just shows up to their next follow-up appointment, they are less likely to end up in the emergency room. This hospital system partnered with Uber, and granted these individuals $100 credits to and from the hospital. This is an example of data driven, innovative thinking that will drive down healthcare costs.   

Want to learn more? Join us on Wednesday, January 20th @ 12:00PM CST to learn more about how Aunt Bertha's Social Service Analytics can help your organization identify trends, cut costs, and effectively guide your decision making.

 Webinar Registration


Topics: leadership Erine Gray data social good reporting analytics

Leveraging Data to Guide Funding Decisions

The holiday season is an important time to connect with loved ones, reflect on our lives, and appreciate what we have. In 2015, our founder, Erine Gray, was awarded the GLG Social Impact Fellowship for his efforts in helping make human service programs more accessible to those in need. Near the end of the year, GLG generously offered to make a contribution, in Aunt Bertha’s name, to the charity of our choice.

When organizations decide to fund programs, services, or missions, there are many different philosophies to help guide their decision making process. Initially, we leaned towards the idea of helping a local organization operating in Austin, TX. However, when we discussed this internally, our Chief Information Officer, Stu Scruggs, had a bright idea. He thought, since Aunt Bertha is a data rich organization that collects information from federal, state, and local programs nationwide, why don’t we conduct an analysis and determine the area that needs the gift most?

Aunt Bertha has data on available programs for each county around the country, and we regularly look at income and poverty rates for these respective areas. Typically, Aunt Bertha’s robust data strategy is used to help more people reach self-sufficiency, but we quickly realized the data was useful to better identify, and select a worthy recipient.

We dove right into the data, and easily determined one of the poorest counties in the country that could really use the extra help this holiday season (below).


After a little research on the U.S. Census Bureau’s Small Area Income and Poverty Estimate (SAIPE)’s database, Aunt Bertha quickly concluded that Shannon, South Dakota would greatly benefit from the money. The county is entirely within the Pine Ridge Indian Reservation, and contains part of Badlands National Park. According to the U.S. Census Bureau, “Shannon County’s population of roughly 13,500 has over 52% of the entire population living at, or below the poverty line.” In May 2015, Shannon County was renamed to Oglala Lakota County, named for the tribal nation that lives there. After the initial research, we ran a program inventory analysis, and looked at the available resources in the specific area.

As we started looking into it, we found a few organizations doing good work in Oglala Lakota. Thunder Valley Community Development Corporation stood out to us because of its reputation and mission: “Empowering Lakota youth & families to improve health, culture and environment of our communities through the healing and strengthening of cultural identity.” Thunder Valley runs multiple projects, and Aunt Bertha helped fund the Youth Shelter Project that serves to shelter at-risk children.


Teams of all shapes and sizes take advantage of data to help drive their decision making processes. Aunt Bertha helps not only program seekers, but also hospitals and healthcare systems to better understand their communities, and successfully provide holistic care.  

Want to learn more about how Aunt Bertha can help your organization with better data? Join us on Wednesday, January 20th @ 12:00PM CST to learn more about how your organization can leverage data to identify trends, and effectively guide your decision making. 

 Webinar Registration


Topics: leadership Erine Gray data social good reporting analytics

What the Search Data Can Tell Us about Community Needs

We live in an increasingly networked world that enables us to find information in seconds and even lets us do things that a few years ago seemed impossible. Want to know how well you slept? There is a device for that. Hate driving? Autonomous vehicles will be hitting the roads soon. Need help finding food or rental assistance in your area? Good luck. Using a typical search engine to find help produces page after page of disorganized information. Often times, the lists even include predatory programs that aren’t actually designed to help those in need.

With seekers having trouble even finding programs, it’s not surprising that nonprofits and governments have an incomplete view of their communities. Are residents accessing the services they need? Are the best programs being funded in the areas where they’re most needed? In many communities, nonprofits and governments cannot answer those questions with confidence.

At Aunt Bertha, we’re doing our part to help answer those questions by making social services information more accessible. We help seekers instantly find programs and services in their area. Each of those searches is logged in our system and helps us provide a snapshot for each community where we have listings. In some cases, the results are what we’d expect: spikes in searches for emergency shelter after a natural disaster. But, we’re also seeing more unexpected results: consistent searches for work programs in communities with dropping unemployment rates. Take Dallas/Fort Worth as an example. From January to May of this year, the unemployment rate steadily declined. But search data from those same months tells a different story.


We know that additional analysis is needed before we can draw definitive conclusions, but this data provides a starting point for that further analysis to understand the why behind the search results.

Our data can also help governments and nonprofits evaluate simple supply and demand questions. Are we funding the programs that people need most? Again, using Dallas/Fort Worth as the example, we see a potential misalignment of service offerings and community needs. Housing and work consistently rank among the highest searched categories, but there aren’t that many programs available that provide those services. At the same time, we see the opposite with care and education related searches. We see lots of care and education programs, but relatively few searches for those services.


While the data certainly does not indicate that we should divert funding one program in favor of another, it does help to tell a story about the community. We can drill deeper and look at specific zip codes to better understand the needs at a hyper-local level. This detailed view provides nonprofits and governments with invaluable insight. And, it’s that insight that we hope will lead to more targeted program development that is responsive to the community needs.   

Want to learn more about the needs in your community? Request a demo below, and we can schedule time to give you an overview.

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Topics: reporting analytics search data community needs