July 2023
As I mentioned in January, we’re actively working to include social determinants of health (SDOH) factors in the assessment and care for our patients. Over the past few months, we’ve highlighted some of our efforts, but I want to revisit the topic and share some exciting developments and updates.
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In February, key SDOH questions were added to the outpatient eCheck-in process.
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An SDOH screening pilot was recently completed with telenursing and case management/social worker teams at HMB 2S, HMCL Med4, HMH Main 4, HMSL 4E and HMWB 7W. Results include:
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21% of screened patients were referred to social work/case management. Most referrals were due to food insecurity and transportation needs. Living standard concerns accounted for 4% of referrals, 2% for utilities and 1% for personal safety.
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Suggested improvements to optimize the screening process so it’s more focused on our patients’ needs. Telenurses identified the need for key talking points with patients to make screening on admission go more smoothly. Social workers and case managers identified workflow gaps to ensure follow up and resource availability for patients.
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Moving forward, the inpatient screening pilot will continue with telenursing at HMH Main 4. To help us better match and refer patients to appropriate community-based organizations, we continue to identify select community partners and are developing an electronic referral process through Epic’s Healthy Planet Link.
We’re also working to optimize Epic workflows and expand our directory of community resources. Our goal is to roll out a comprehensive SDOH screening and referral process systemwide by the end of 2023. Critical to this effort is ensuring we address everything that may help our patients receive the assistance and follow up they need.
This promises to be a tremendous benefit to our patients, while also ensuring that we meet CMS requirements for SDOH screening of inpatients by 2024. I will share more details and education resources as this effort continues to move forward.
As always, if you have thoughts or comments, you’d like to share, please click the link below.
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