Addressing SDH through a Comprehensive Screening and Referral - - PowerPoint PPT Presentation

Addressing SDH through a Comprehensive Screening and Referral Program

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Nimisha Singh MPH Candidate, Shari Jardine MPH MA, Rachael Odusanya, Omolara Uwemedimo MD MPH, Johanna Martinez MD MS, Eun-Ji Kim MD

Social Determinants of Health

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range

• f health, functioning, and quality-of-life
• utcomes and risks1
• There has been a stronger initiative for

healthcare providers to not only address the medical needs of patients but also the social needs of the patients

• Few healthcare settings have

incorporated an adequate SDH screening program to help address the needs of the patients

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1 Social Determinants of Health | CDC. (2019, April 9). Retrieved October 15, 2019, from https://www.cdc.gov/socialdeterminants/index.htm

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Objectives

• To decrease the identified adverse SDH amongst the

patients in our primary care practices that engage in

• ur screening and Patient Navigator (PN) program

from June 2018-October 2019

• To establish bidirectional community partnerships

to assist and refer our patients with adverse SDH who screen positive for SDH needs from June 2018-October 2019

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Our screening tool is translated into Haitian Creole and Spanish

Community Partners

Hofstra | Northwell Medical Legal Partnership

An MLP embeds lawyers into clinical care settings to identify and address legal issues that affect social determinants of health2 which are called health harming legal needs.

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Child Center of New York

The INN

2 Medical-Legal Partnership FAQ. (n.d.). Retrieved October 25, 2019, from https://medical-legalpartnership.org/faq/

Workflow

Clinical Sites: 2 Internal Medicine & 1 Pediatric ambulatory care practices

• Distribute Life and Wellness Screen to new patients and at annual wellness visit
• PN assist with screens in waiting rooms and exam rooms
• PN’s are integrated into clinical workflows
• PNs training:
• Two weeks long
• Content includes – information sessions from community partners, motivational

interviewing, cross-cultural care, and SDHs, role-plays and shadowing Over 75% of PN’s are bilingual across the clinical sites Inclusion Criteria:

• Patients select at least 1 SDH need AND select wanting assistance from PN

Exclusion criteria:

• Patient does not select any SDH needs OR declines wanting assistance

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Patient gives completed screen to Front Desk/Provider

• r back to PN

Patient refuses screen

End of process

Patients presenting for annual well visits receive screen in waiting room

Non-Emergent Social Needs indicated Emergent Social Needs indicated No Social Needs indicated

PN makes a plan with Social Worker/Providers

• n-site to address

emergent needs

• Domestic Violence
• Homelessness
• Imminent Eviction
• Imminent

Deportation PN begins referral and follow-up process within 48 hours

Screening Process

Referral and Follow-Up Process

Intake interview to review results of screen with patient and determine what referrals are needed (within 3 days after screen) Referrals: PN researches community resources to address pt.’s needs, gives referrals to patient Follow-Ups: PN follows up w/ patient every 2 weeks to check on status of referral and patient’s social needs PNs continue with referral & follow-ups for 12 Weeks

• r until patient does not

need further assistance Completion Call: final phone interview to get feedback on patient experience and status of SDH

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Methods

1. Screens received from patients 2. Data from the screens entered into REDcap 3. Patients who met exclusion criteria were closed out in REDcap 4. Patients who met inclusion criteria were given an intake call within 1 week of the initial screen

• Contact information obtained from Electronic Medical Record

5. During intake, PN discusses the aim of the study, details of the SDH needs of patients, and patient goals

• If patient indicated health harming legal needs, they are given a legal consent form in
• rder to participate in the Medical Legal Partnership
• Patient contacted by Legal Intake Coordinator to address their legal needs

6. Within one week of intake, PN contacts patient with resource contact information based

• n their needs
• Community Based Organization
• Health Homes
• Social Work
• 7. Following Resource call, patient was contacted for 12 weeks or until they indicated they no

longer wanted to participate or they longer have any needs

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Results as of October 2019

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Adult Medicine Clinic

• Total screens 1,335
• 828 patients

screened POSITIVE for SDH needs

• 279 accepted

assistance from PN

• 99 Patients referred

to MLP

• 12 cases consulting

with legal team

Note: Screening at this site began in May 2018

MSGO

• Total screens 124
• 65 patients

screened POSITIVE for SDH needs

• 34 accepted

assistance from PN

• 9 Patients referred

to MLP

• 4 cases consulting

with legal team

Note: Screening at this site began in August 2019

Pediatric

• Total screens 1,901
• 1035 patients

screened POSITIVE for SDH needs

• 514 accepted

assistance from PN

• 66 Patients referred

to MLP

• 17 cases

consulting with legal team

Program Successes

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Embedding Patient Navigators in Clinical Workflow Screening comprehensively for social needs across multiple domains Prioritizing Cultural Competency Community Partners & Medical Legal Partnership

THANK YOU!

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Contact Information: Nimisha Singh nsingh60353@gmail.com