How Internal and External Collaborations Launched a System-wide Social Health Screening and Referral Initiative

Abstract

Background

In 2019, addressing the social health needs of patients was identified as a top priority for the health system through the Community Heatlh Needs Assessment. As plans were underway to implement a social health screening, the pandemic occurred and amplified more pressing priorities for the health system. The COVID-19 pandemic, however, exacerbated social needs and worsened disparities for patients. This elicited a refocus on implementing a system-wide social determinants of health (SDOH) screening and referral process.

Methods

This initiative utilized both internal and external collaborations. Internal collaborations included the development of a leadership committee with various departments to inform the SDOH rollout. The primary grant project site, provided feedback to refine the SDOH process. A key external collaboration included a care coordination platform's Team. This platform provides patient connectivity to community organizations that support their social health needs identified through screening.

Results

From April through November 2022, the health system has successfully conducted over 8,000 social health assessments and over 2,500 community referrals through the care coordination platform.

Conclusion

The leadership committee collaboration informed tactics to streamline the screening process. This included technical updates in our electronic medical records system, screening requirements, an appropriate timeline for onboarding outpatient clinics. The feedback provided by the clinic team facilitated the development of an online, self-paced training module to prepare clinic teams for SDOH implementation. These findings demonstrate the successful implementation of a new initiative through internal and external collaborative efforts within a health system

Keywords

Collaboration, Social Determinants of Health (SDOH), Health System, COVID-19, Disparities, Care Coordination, Population Health

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How Internal and External Collaborations Launched a System-wide Social Health Screening and Referral Initiative

Background

In 2019, addressing the social health needs of patients was identified as a top priority for the health system through the Community Heatlh Needs Assessment. As plans were underway to implement a social health screening, the pandemic occurred and amplified more pressing priorities for the health system. The COVID-19 pandemic, however, exacerbated social needs and worsened disparities for patients. This elicited a refocus on implementing a system-wide social determinants of health (SDOH) screening and referral process.

Methods

This initiative utilized both internal and external collaborations. Internal collaborations included the development of a leadership committee with various departments to inform the SDOH rollout. The primary grant project site, provided feedback to refine the SDOH process. A key external collaboration included a care coordination platform's Team. This platform provides patient connectivity to community organizations that support their social health needs identified through screening.

Results

From April through November 2022, the health system has successfully conducted over 8,000 social health assessments and over 2,500 community referrals through the care coordination platform.

Conclusion

The leadership committee collaboration informed tactics to streamline the screening process. This included technical updates in our electronic medical records system, screening requirements, an appropriate timeline for onboarding outpatient clinics. The feedback provided by the clinic team facilitated the development of an online, self-paced training module to prepare clinic teams for SDOH implementation. These findings demonstrate the successful implementation of a new initiative through internal and external collaborative efforts within a health system