Leveraging the experience of several physician practices already screening patients for social determinants of health (SDOH) Montefiore Health System recently rolled out a two-tiered assessment program to measure SDOH positivity in its predominantly high-risk, government-insured population.
Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services outlines Montefiore's approach to identifying SDOH markers such as housing, finances, healthcare access and violence that drive 85 percent of patients' well-being, and then connecting high-need individuals to community-based services.
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In this 25-page resource, Amanda Parsons, MD, MBA, vice president of community and population health at Montefiore Health System, walks through her organization's SDOH initiative, from screening ramp-up to challenges and considerations to initial findings and next steps.
In this 25-page report, Dr. Parsons shares the following program elements:
- Industry, financial and population-based considerations driving the need for SDOH assessment within Montefiore's 700,000 patients;
- SDOH screening instrument criteria and selection, including SDOHs addressed by each tool;
- Population SDOH risk stratification and follow-up support for patients identified as high- and lower-risk for SDOHs;
- Physician practice guidelines for targeting and screening of populations;
- Examples of SDOH screening implementation by physician practice;
- Factoring of patient needs into SDOH workflow creation;
- Recommendations for community referral support tools, including NowPow;
- Engagement of Montefiore physicians in SDOH assessment;
- Initial SDOH findings, program barriers and limitations;
- Examples of engaging the community surrounding Montefiore in addressing SDOHs, including a neighborhood initiative to improve nutrition;
- Achievements and next steps;
- The challenges of addressing SDOHs when little reimbursement exists;
- and much more.
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P.S. -- You may also be interested in these SDOH resources from HIN: