Screening for Social Determinants in Primary Care

By Jamie Cetrone | Categories: | Comments Off on Screening for Social Determinants in Primary Care

Internal: ambulatory care, social work, healthcare financial counselors, care management
Community partners: New York Legal Assistance Group (NYLAG) Legal Health Program, Community Service Society of New York, Bronx Works, Public Health Solutions

This program got started at a retreat held by the Ambulatory Care Department. It was one of several ideas for improving our services that gained wide support. A workgroup was formed with the goal of developing a social determinants screening tool and referrals to helpful resources. The ultimate goal is to improve the health status of our patient population, by improving social and economic influences on health.

Having designed a screening tool informed by multiple hospital stakeholders, as well as partner organizations, we are ready to implement the tool at nurse led visits for diabetes, hypertension, and depression management. If we show positive outcomes, we hope to implement the tool more widely. Depending on the answers to the screen, nurses will refer to known entities in the hospital including social work, a legal health program, healthcare financial counselors, and a table staffed by a partner non-profit where patients can enroll in the food stamp program. The screening tool covers multiple domains, including housing, food insecurity, housing conditions such as pests and mold, health insurance and health care cost barriers, immigration, and domestic abuse, among others. There has been no additional funding for the program. With respect to staffing, in addition to nursing and departments already mentioned, the project is supported by the population health team in Ambulatory Care. The screen is in paper form, and data from the screen will be manually entered into an Access Database; thus there has been as yet no IT support for this program.

The working group behind the program has been multidisciplinary, consisting of population health staff, physicians, nurses, clerical and finance staff, social workers, lawyers from the Legal Health program onsite, and staff from partner NGOs specializing in housing, food stamps, and health insurance advocacy. There has been some liaising with care managers and the ED, to explore the use of the screening tool on high risk populations.

We have recently identified our outcome measures as being: A1C scores, BP scores, show rates to nursing visits, show rates to PCP visits. Our theory is that when we connect patients to resources to address their economic and social problems, our patients are better able to manage their health care appointments, have the resources necessary to improve their health status (such as buying better quality food), and with the reduced stress of dealing with economic and social problems, have more mental wherewithal to address their chronic diseases. We intend to compare patient populations who are administered the tool, to those that are not, to see the effect of systematically screening for social determinants. We intend to share the referral resources will all providers however from the get-go, so that all patients are aware of the linkages and resources we have identified through the program. We have no results to date as we are just getting set to test the screening tool to gage if it’s easy to understand and self-administer, and whether the referral pathways work.