Bronx RHIO Launches “Facesheet” Client Summary Tool

The Bronx RHIO has implemented a new custom reporting tool called the Facesheet for one of its longstanding community based-organization (CBO) members, BronxWorks. The Facesheet provides a quick snapshot of client demographics and medical history upon registration in a BronxWorks program.

The Facesheet was developed specifically for CBO staff to streamline the client intake process. In close collaboration with BronxWorks, the Bronx RHIO designed the Facesheet to include only the most pertinent information in a straightforward format. Bronx RHIO worked with BronxWorks staff to establish a report delivery mechanism that fits in with existing workflows: the Facesheet is only delivered to staff who need to see it, and it is generated only in specific circumstances.

The Facesheet includes important medical history information such as the client’s most frequent diagnoses, hospital utilization history, social determinants of health data including veteran status and preferred language, and risk scores for two preventative care measures: emergency department visits and inpatient readmissions. The data is generated in real time, and risk scores are refreshed on a monthly or weekly basis, respectively.

BronxWorks was founded nearly 50 years ago and has a mission of helping individuals and families improve their economic and social well-being. They offer a variety of services to their clients, including homeless services, benefits assistance, chronic illness management, supportive housing, services for older adults, and more.

With the addition of the Facesheet to their workflow, BronxWorks is able to get a clearer assessment of each client’s needs and place them in the most suitable program with the appropriate level of care management. BronxWorks staff are made aware of past and possible future issues in a succinct, on-demand report.

BronxWorks and its clients tangibly benefited from the Facesheet during the COVID-19 pandemic, as the client’s COVID-19 test results were added to the Facesheet data. This allowed staff to support their Supportive Housing and Shelter program clients testing positive by providing them with PPE, explaining quarantine procedures and sanitization, educating them about symptoms to be aware of that would indicate that they should go to the hospital, and ensuring that the clients had access to food during their quarantine. The knowledge of test results alerted BronxWorks staff to be sure that they were following best practices for PPE use and handwashing whenever they were making contact with clients, which probably contributed to the low infection rate and few sick days by staff.