Beyond Silos: A Vision for Connected, Equitable, and Compassionate Care

‍Breaking the Cycle of Healthcare Fragmentation

The U.S. healthcare system spends an estimated $4.3 trillion annually, yet it ranks last among high-income countries for overall performance.¹ A significant contributor to this inefficiency is poor care coordination, which costs the system over $27.2 billion annually in avoidable hospital readmissions.² This disconnect also affects patients directly: 41% of Americans report experiencing a gap in communication between providers, leading to delays in care or conflicting medical advice.³

Transitions of care are the most illustrative of these challenges. For instance, critical details are often lost as patients move from a hospital to a skilled nursing facility (SNF) and then home. Nearly 80% of serious medical errors involve miscommunication during care transitions.⁴ Informal caregivers, who shoulder much of the burden, are left to navigate a broad range of issues, including complex care plans, medications, a maze of appointments, and social service needs without adequate support.

Why Many Solutions Fall Short

Technology developers introduce new platforms every year, often promising to revolutionize care. Yet many of these solutions fail to understand users’ needs and don’t consider the broader ecosystem. For example, standalone telehealth platforms or chronic disease management apps often operate in isolation, exacerbating the fragmentation rather than alleviating it.⁵

While innovative models like Programs of All-Inclusive Care for the Elderly (PACE) showcase the potential for integrated care, they remain limited in scope and accessibility. Most patients and their caregivers continue to face a siloed, piecemeal system that doesn’t meet their needs. As technology and data integrations evolve, there is an opportunity to radically improve the system without disrupting provider workflows.

Centering on the Individual and Informal Care Team

A community of caring starts with recognizing that health extends beyond clinical interactions. It includes the informal care teams — family members, friends, and neighbors — who are pivotal in supporting patients. Nearly 53 million Americans provide unpaid caregiving, with an average of 24 hours per week dedicated to tasks like managing medications, attending appointments, and helping to support activities of daily living.⁶ Yet, these caregivers often report feeling invisible within the healthcare system.⁷

Empowering these care teams with accessible tools and resources tailored to their needs can transform their ability to provide effective support. However, these solutions often fail to integrate with existing workflows, exacerbating fragmentation. User-centric technology solutions offer a way to improve care and communication during these transitions.

The hypothetical example of Marta, a 76-year-old cardiac rehab patient, exemplifies the challenges and opportunities of the community-of-caring approach.

After being discharged from a skilled nursing facility, Sarah’s daughter used HealthHive to manage her care. The ease of collaboration and communication reduced stress for Sarah and her daughter, ensuring a smoother transition and a faster recovery. Here’s how:

• A digital prepare-for-home checklist that allows everyone to get ready for a successful return home.
• A digital care plan that helps the individual and informal care team know the daily tasks and activities necessary to support care.
• Communication tools that enable patients and their care teams to stay connected and on the same page, allowing timely updates.
• Remote patient monitoring (RPM) capabilities support health workers and caregivers in tracking and reporting patient progress efficiently.
• Educational resources empower families to understand the conditions of their loved ones and for caregivers to perform advanced tasks like medication management and basic clinical assessments, fostering better support for patients transitioning between care settings and remaining at home.
• Connections to community resources for things such as transportation to cardiac rehabilitation or heart-healthy meal delivery services.
• A place to bring comfort to patients, families, and the informal care team that the “team” is engaged and understands their needs and preferences.

Supporting Providers Without Additional Burdens

Healthcare providers face their own set of challenges. With increasing patient complexity, regulatory requirements, and administrative tasks, burnout is at an all-time high — affecting over 63% of physicians in the U.S. in 2022.⁸ Adding another layer of technology or workflows is not the solution. Instead, solutions should be integrated into electronic health records (EHRs) and other workflow systems.

Enhancing current workflows rather than disrupting them can help providers focus on delivering coordinated, patient-centered care. For instance, enabling updates from home health aides or social workers can improve continuity of care without adding administrative overhead.

Bridging the Silos: Connecting Clinical and Social Care

Health doesn’t happen in isolation; social determinants like housing, food security, and transportation shape it. Research shows that social determinants account for up to 80% of health outcomes.⁹ However, traditional healthcare systems often fail to integrate these factors into care delivery.

A community of caring bridges this gap by connecting clinical care with social services. For example, integrating referral systems for housing support or meal delivery into care plans ensures that patients’ non-medical needs are recognized. Studies have shown that addressing these determinants can reduce hospital readmissions by 50% and improve patient satisfaction significantly.¹⁰

How HealthHive is Addressing the Gaps

HealthHive is building a platform to support the community-of-caring model, offering a way to connect patients, caregivers, and providers. Rethinking care coordination and leveraging technology empowers all stakeholders involved in the care journey.

Empowering Patients and Care Teams with the Hive

The Hive, HealthHive’s patient-facing component, is designed to simplify care management for patients and caregivers. Unlike traditional systems that overwhelm users with data, the Hive is evolving to deliver actionable insights tailored to individual needs. Notably, the Hive creates a unified record of the individual that remains with them throughout their lifetime journey.

Supporting Providers with the Portal

On the provider side, HealthHive’s Portal integrates with existing EHR systems to provide patient care insights. For example, a primary care physician can view updates from a home health aide or social worker, ensuring everyone is on the same page. This reduces errors, enhances coordination, and supports value-based care initiatives.

Transforming Care Transitions

Care transitions are a cornerstone of HealthHive’s approach. By ensuring that patients, caregivers, and providers are aligned at every step, the platform reduces the risk of readmissions and empowers patients to confidently navigate complex healthcare journeys.

Moving Forward: A Collaborative Effort

To create a healthcare system that works for everyone, we must prioritize connection over fragmentation. Building a community of caring is not just an aspirational idea — it’s a necessity. The stakes are high: poor care coordination costs billions of dollars, diminishes patients’ quality of life, and erodes trust in the system.

To move forward, stakeholders must collaborate: HealthHive focuses on supporting actionable shared insights rather than overwhelming users with data.

• Healthcare providers should advocate for tools that enhance, rather than disrupt, their workflows.
• Technology developers must focus on integration and user-centric design.
• Policymakers should align incentives to reward holistic, coordinated care.

We can achieve better outcomes, lower costs, and a more compassionate healthcare system by embracing a community-of-caring approach.

Footnotes:

1. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, DC: National Academies Press, 2001).
2. “Mirror, Mirror 2021,” The Commonwealth Fund, August 2021, https://www.commonwealthfund.org/publications/fund-reports/2021.
3. Suzanne J. Schramm et al., “Hospital Discharge and Readmission,” Journal of Hospital Medicine 11, no. 7 (2016): 536–542.
4. Matthew Weiner et al., “Health IT Adoption in Healthcare Organizations,” Journal of Healthcare Informatics 26, no. 3 (2020): 112–121.
5. AARP and National Alliance for Caregiving, Caregiving in the U.S. 2020 (Washington, DC: AARP, 2020).
6. Lynn Friss Feinberg, “Family Caregiving: A Vision for the Future,” Generations 42, no. 2 (2018): 35–41.
7. “National Physician Burnout & Depression Report,” Medscape, 2022.
8. Sanne Magnan, “Social Determinants of Health 101 for Health Care,” National Academy of Medicine (October 9, 2017).
9. Elizabeth Bradley et al., “Social Determinants of Health: Opportunities to Improve Health Outcomes,” Journal of the American Medical Association 320, no. 16 (2018): 1621–1622.
10. AARP, “2021 Home and Community Preferences Survey,” https://www.aarp.org/research/2021.
11. National Institute on Aging, “Community-Based Care: A Cost-Effective Alternative,” 2022.

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