DiverCity

Social Architecture for FHIR-based Referral and Open Standards Networks (SAFFRON Labs) is a fully owned subsidiary of NewWave. 

SAFFRON Labs is dedicated to imagining and building the technical ecosystem for delivering person-centered care that reduces the burden of incorporating social services available to ameliorate the Social Determinants of Health (SDoH).

There isn’t an open, standards-based platform that enables secure sharing of SDOH data in the US today.

Social determinants of health (SDOH) significantly impact health outcomes for all, with a disproportionate impact on vulnerable populations.

Understanding and addressing SDOH downstream and upstream can improve the health of both individuals and communities.

The main challenge is the lack of secure information exchange for care coordination (clinical, social, and human services) to effectively provide whole-person care. A secure exchange platform that enables interoperability across sectors and stakeholders of all types (Public and Private) is needed to address these persistent inefficiencies that rob the nation of better outcomes.

NewWave built the DiverCity platform using the Gravity Implementation Guide to address health equity and improve health. DiverCity coordinates the end-to-end effort of the patient assessment and closed-loop referral. It is made up of three main applications addressing the practitioner (Pulse), the patient (Clarity), and the Community-Based Organizations (CBOs) (Magnet). DiverCity integrates these three personas in the SDOH patient assessment and closed-loop referral.

NewWave has made it easy for CBOs to upload any files into Magnet. Magnet’s AI reads the uploaded documents and converts them to JSON or FHIR. DiverCity’s analytics and dashboards display quantitative and qualitative Health Equity Data. 

The DiverCity platform has numerous survey instruments such as Protocol for Responding to and Assessing Patients’ Assets, Risks & Experiences (PRAPARE), Hunger Vital Signs (HVS), a Lead Risk Questionnaire, and a COVID-19 Patient Screening Questionnaire. We have conducted quantitative research, tallying COVID-19 health impacts, risk factors, food access, and concerns related to the SDOH. Food access and security questions were adopted directly from the HVS survey data. 

Who? The underserved population in the United States. 

Newwave/Saffron Labs built the DiverCity Platform in lockstep with the Center for Medicare and Medicaid Services (CMS) Value-based care initiative. We believe that Health equity is achieved when everyone has a fair and just opportunity to attain optimal health. Value-based care advances health equity by:

• Putting focus — and having a measurable impact — on the health outcomes of every person, including those from underserved populations.
• Encouraging health care providers to screen for social needs and work with individuals to develop personalized treatment plans that can address each person’s unique needs — such as connecting them to a local food bank, engaging with interpreter services, or arranging transportation or other accommodations.
• Requiring health care providers to monitor and track outcomes across populations to assess for disparities and intervene as necessary to help close gaps in access or care.
• Engaging with providers who have historically worked in underserved communities and providing necessary resources and support to meet this health equity goal.

DiverCity brings all of these actionable items together in one platform. DiverCity coordinates the end-to-end effort of the patient assessment and closed-loop referral. It is made up of three main applications addressing the practitioner (Pulse), the patient (Clarity), and the Community-Based Organizations (CBOs) (Magnet). DiverCity integrates these three personas in the SDOH patient assessment and closed-loop referral.

NewWave is a member of the HL7 Accelerator Gravity Project. This is a diverse collaboration of experts committed to solving the information exchange needs that advance health equity. It aims to develop and advance open data standards using HL7, FHIR, and associated technologies that form modern social care interoperability. The project's name reflects the driving influence of the context and the Social Determinants of Health (SDOH) and a move toward medical integration. Documenting and sharing SDOH-related assessment, diagnosis, and treatment information using modern coding and exchange standards can improve health outcomes.

As a HL7 and the Gravity Project member, Newwave understands the FHIR Technology and has implemented FHIR Technologies to address the CMS Interoperability and Patient Access Final Rule (CMS-9115-F).

We are on the cusp of operating in a pilot, but the paperwork with the potential client has not yet been signed off. We have been operating in the prototype phase, getting industry feedback on the applications so that they can be pilot-ready.

We are applying to the MIT Solve challenge because we believe it offers a unique opportunity to accelerate the development and implementation of our solution to address healthcare disparities in underserved communities in the United States. MIT Solve's mission to drive social impact through innovation aligns closely with our goals of leveraging technology to improve access to healthcare and empower underserved communities. It aligns with the CMS Value-Based Care Initiative, and we believe both go hand in hand. We think MIT Solve can provide us with the support to overcome several key barriers.  

Financial Barriers:

Additional financial resources are needed to scale our solution effectively and secure sufficient funding to support its development and implementation. MIT Solve's network of partners and potential funders presents an invaluable opportunity to access the financial support needed to advance our solution.

Legal and Regulatory Hurdles:

The legal and regulatory landscape in the healthcare sector in the United States can be complex. Compliance with data protection regulations, intellectual property rights, and healthcare standards requires careful consideration and legal guidance. Solve's legal experts and partners network can provide valuable insights and support in navigating these complexities.

Cultural and Market Considerations:

We firmly believe that our solution can work outside the United States, especially in countries where the government subsidizes healthcare. Our research shows that some countries still use the paper referral method to request services for beneficiaries. We need support in conducting extensive market research, user testing, and cultural sensitivity training to ensure that DiverCity meets the needs and preferences of diverse populations. Additionally, building trust and partnerships within local and international communities is crucial for the adoption and sustainability of our solution.

At Saffron Labs, we recognize the persistent systemic inequities and institutional failures that lead to reduced access to healthcare and poorer health outcomes for Black and Brown communities in the US. Our platform, DiverCity, is designed specifically to bridge these gaps, ensuring that healthcare equity is not just an ideal, but a reality. 

Saffron Labs innovates by focusing on the integration and interoperability of healthcare technologies with a specific emphasis on the Social Determinants of Health (SDOH). Their platform leverages FHIR standards to enable seamless data sharing across diverse healthcare and community-based stakeholders, enhancing patient-centered care. By addressing SDOH, Saffron Labs aims to improve health outcomes, particularly for vulnerable populations, through a secure and open exchange system. This approach not only meets current health sector needs but also pioneers the promotion of health equity and effective community healthcare strategies. 

DiverCity, by Saffron Labs, is set to significantly impact healthcare by ensuring comprehensive patient care management. This product uniquely coordinates the entire process, from patient assessment to ensuring they receive the necessary services through a closed-loop referral system. This approach is efficient in value-based care models, which prioritize long-term health outcomes and cost efficiency. By focusing on Social Determinants of Health (SDOH), DiverCity facilitates a holistic view of patient health, enabling better integration of medical services and improved health outcomes overall. 

Saffron Labs aims to demonstrate the effectiveness of DiverCity within a Managed Care Organization (MCO) to address challenges in value-based care. The impact goals are centered on improving efficiency and outcomes in healthcare delivery, particularly through better management of Social Determinants of Health (SDOH). Progress towards these goals is measured by tracking improvements in patient health outcomes, reductions in healthcare costs, and enhanced coordination of care. This evaluation involves assessing the system's performance in real-world settings to validate its impact on healthcare services. 

FHIR

Flutter

Azure Cloud

Permify

Keycloak

Twenty (20)

3 years

At Saffron Labs, ensuring team diversity and inclusivity is paramount. The team is globally diverse, with members from India, the US, Kenya, and Nigeria, reflecting a broad range of ethnic groups. Leadership is shared across these diverse backgrounds, promoting an environment of trust. Critical to the organization's decision-making process is that no decision proceeds without full team consensus, ensuring that all voices are equally heard and valued. This approach not only fosters a welcoming atmosphere but also minimizes barriers to opportunity for all staff members

DiverCity scales and impacts the population it serves in two ways: It's product and its process.

1. The Product

The beneficiary or patient is at the center of the Value-Based Care initiative. Thus, the Clarity application will be offered to all patients for Free. 

Community-based organizations (CBOs) are pillars in underserved communities that lack the technological prowess or Infrastructure to implement the necessary technologies to allow the sharing of information or the means required to implement the processes or technology to mitigate the use of Business Associate Agreements between HIPAA-covered and noncovered entities. Thus, all CBOs onboarded to DiverCity for Free will be given the Magnet Application free of cost.

Per CMS Administrator Chiquita Brooks-LaSure, "As part of CMS’ health equity goals, CMS are rewarding hospitals that deliver high-quality care to underserved populations and, for the first time, also recognizing the higher costs that hospitals incur when treating people experiencing homelessness." "With these changes, CMS is laying the foundation for a health system that delivers higher quality, more equitable, and safer care for everyone.” The CMS final rule will increase operating payment rates of 3.1% for Hospitals or Managed Care Organizations. 

Hospitals and Managed Care Organizations are incentivized to help the underserved population. All providers using the DiverCity Platform will have the Pulse application fully integrated with their EHR System so that patients can be fully helped effectively and efficiently. Pulse will be offered at a subscription cost to MCOs, Hospitals, or Providers.

2. Process

Since the patient is at the center of value-based care, the DiverCity Platform has become a very powerful platform for all to use. This means that as an MCO procures DiverCity, all CBOs that work with the said MCO can be onboarded quickly. Thus, a dynamic ecosystem of providers and patients will be created, and a state-of-the-art CBO directory will be created to accept referrals for impacted patients.

Goals:

• Within the next 12 months: operational sustainability; i.e. activities are accurately costed and funds cover 30% - 50% of costs 

• 2025 and beyond: financial sustainability, i.e., effective and consistent cost management to continuously build up surpluses to reinvest back into the organization.

Financial strategies: 

Immediate to short-term (2024)

• Continue to pilot the application

• Start a Subscription pricing model for partners in the United States

• Develop a financial model for a licensing

Medium-term (2025-2026)

• Build a strong impact and business case Divercity

• Seek projects for value-based care or health equity. Whether through the Center for Medicare and Medicaid Services (CMS) or through Managed Care Organizations (MCOs) to increase profit margins

• Establish commercial partnership models developing solutions for for-profit and nonprofit organizations. 

Long-term (2026 and beyond)

• Provide this solution to countries where the government provides Health Care Services. There are countries that lack the technology for making referrals, etc. Some countries are still using the paper method for making referrals