In Montefiore Social Determinants of Health Screening,
Patients' Needs Shape SDOH Workflow
In Dr. Amanda Parsons' 20-something years in healthcare, she has never implemented a program as widely embraced as Montefiore Health System's Social Determinants of Health (SDOH) screening.
"It was one of the few times in my career that I didn't encounter physician resistance," said Dr. Parsons, Montefiore's vice president of community and population health. The health system's screening assesses patients for a host of SDOH factors that drive 85 percent of their well-being, including housing, food security, access to care or medications, finances, transportation and violence.
Following assessment, the goal is to connect individuals who screen positively for SDOHs with assistance from the area's robust network of community organizations.
Dr. Parsons outlined her organization's SDOH screening process, findings, challenges, and future plans during Assessing Social Determinants of Health: Collecting and Responding to Data in the Primary Care Setting, a June 2017 webcast by the Healthcare Intelligence Network now available for rebroadcast.
In case you missed this webinar, you still have a chance to watch this highly-rated program.
Register to view the conference today or order your training DVD or CD:
To get started, Montefiore piggybacked on the efforts of a few provider sites already screening for SDOHs. It then offered providers a choice of two validated screening tools, the first developed at a fifth-grade reading level, the second a more sophisticated "stressor" screen. Thirdly, it built a two-tiered triage system that leveraged social workers for individuals with very high SDOH needs, and community health workers to assist with lower-level needs.
Referrals would come from existing data banks or a host of new online referral tools, many of which Dr. Parsons mentioned during the webcast.
Interestingly, while Montefiore is fully live on an EPIC® electronic health record, SDOH screenings are currently conducted on paper, noted Dr. Parsons. This decision was one of multiple considerations in workflow creation, including respect for patient privacy.
For the time being, each Montefiore provider site selects a unique population to screen—or opts not to screen at all, if staffing is lacking. For example, one site screens all patients scheduled for annual physicals, while another screens patients recently discharged from the hospital.
In an initial readout of both screens, SDOH positivity was highest for housing and finances.
By the end of 2017, Montefiore expects to have completed more than 10,000 screenings. The health system, which serves some 700,000 patients, also plans to boost its ranks of community health workers, broadening its referral network.
Looking ahead, Montefiore will address a number of key administrative and emotional barriers. Some patient issues, like overcoming the stigma of seeing a social worker, can be minimized with a simple scripting change. Others, like alleviating an individual's financial pain or putting a roof over a family's head, are much more complicated.
Also needed is a process to confirm a patient has "gone that last mile" and obtained the recommended support, Dr. Parsons added.
As it expands SDOH screening, Montefiore is banking on that swell of engaged providers. As part of its mission to provide comprehensive, 'cradle-to-grave' care for its mostly Medicaid and otherwise government-insured population, Montefiore "intervenes even when there is no payment structure for that work," said Dr. Parsons.
Falling into that category is SDOH screening. "Much of the Social Determinants of Health work is not very billable in the traditional paper service model, but it is incredibly important to do, regardless."
You can "attend" this program right in your office and learn more about Montefiore's SDOH screening process and SDOH clinical workflow, It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.
You'll get to listen to the question and answer session to hear details on: successful strategies for engaging patients in specific interventions addressing SDOH; overcoming provider resistance to SDOH screening; and support for the social workers and community health workers addressing SDOH.
Here's what participants said about the program:
"We are in the process of setting up a similar screening process and it was very helpful to hear how they have gone about doing theirs. We will be able to use the information from the webinar to create a more effective process," said one participant.
"We will likely develop and adopt a different questioning rubric based around the different response types presented during the webinar," another participant noted.
To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Assessing Social Determinants of Health: Collecting and Responding to Data in the Primary Care Setting, please visit:
You may also be interested in these resources on social determinants of health from the Healthcare Intelligence Network: