Link2Outcome: Coordinating Social Care and Health Care using Semantic Web Technologies - Scenario

We showcase the system through a business case for integrated care. The users of the system may have various roles within the health and social care administration, and they are not familiar with semantic technologies. We outline the features and functions the system provide in two use cases, as well as illustrating the central role played by semantic technologies to derive meaningful and useful information from heterogeneous and distributed data sources, published by different agencies or authorities.

In this use-case, we describe two main roles: the primary care provider (physician) and the care manager (or coordinator). In our particular case, a primary care provider can refer a person that potentially has vulnerabilities spanning beyond healthcare to a care manager and the latter can assess the needs of person and coordinate interventions across different dimensions (e.g. social, clinical).

As an illustrative example, a patient named Bob visits the physician and is diagnosed with pre-CHF (Congestive Heart Failure) condition and obesity. He has an unhealthy diet and sedentary life style. The physician can access the different medical information from various systems to obtain a complete clinical view. The primary care provider can see vitals (e.g., weight, pressure), symptoms (such as cough, wheezing and shortness of bread), medications, allergies, lab tests, care plans, and family history of CHF as well as analytics results (risk stratification). His care plan requires implementing lifestyle changes, such as healthy heart diet and exercise.

Bob's clinical issues are complicated with social issues - unemployment - and signs of depression. Thus, Bob is referred to integrated care by the physician to help him achieve necessary lifestyle changes and receive proper counseling and services (e.g., social benefits or referral to a nutritional programme). Bob has been registered on the system and he has given his consent to accept services through the health home. The assigned care manager can review Bob’s medical, social and behavioral situation, across both health and social care systems. In order to asses the individual risks and the variables that influence care, the relevant contextual information includes: social needs (e.g., does the person own a house, are they homeless?), personal details (age, gender, ethnicity), health history, entire family situation and even places or communities where she belongs (deprivation and morbidity indexes). Based on the information above, the care manager can make informed decisions concerning treatments plans, involving additional services (e.g. social service, income support) or including family members.