Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services

Assessing Social Determinants of Health:
Screening Tools, Triage and Workflows to Link
High-Risk Patients to Community Services

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 ServicesAssessing 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.

For more information or to order your copy today, please visit:
http://store.hin.com/product.asp?itemid=5244

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.

Order your copy today online:
http://store.hin.com/product.asp?itemid=5244

Available in Single or Multi-User Licenses

A multi-user license will provide you with the right to install and use this information on your company's computer network for an unlimited number of additional workstations within your organization for a one-time fee. To have this valuable resource on your network, or to inquire about ordering bulk copies in print or Adobe PDF, please e-mail sales@hin.com or call 888-446-3530.

P.S. -- You may also be interested in these SDOH resources from HIN: