Addressing SDH through a Comprehensive Screening and Referral Program Nimisha Singh MPH Candidate, Shari Jardine MPH MA, Rachael Odusanya, Omolara Uwemedimo MD MPH, Johanna Martinez MD MS, Eun-Ji Kim MD 1
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 of health, functioning, and quality-of-life outcomes and risks 1 • 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 2 1 Social Determinants of Health | CDC. (2019, April 9). Retrieved October 15, 2019, from https://www.cdc.gov/socialdeterminants/index.htm
3
4
Objectives • To decrease the identified adverse SDH amongst the patients in our primary care practices that engage in our 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 5
Our screening tool is translated into Haitian Creole and Spanish 6
Community Partners The INN Hofstra | Northwell Medical Legal Partnership An MLP embeds lawyers into clinical care settings to identify and address legal issues that affect social determinants of health 2 which are called health harming legal needs. Child Center of New York 7 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 8
Screening Process Patient gives Patients presenting for completed screen to annual well visits Front Desk/Provider receive screen in or back to PN waiting room Patient refuses screen Non-Emergent Emergent Social No Social End of Social Needs Needs indicated Needs process indicated indicated • Domestic Violence • Homelessness • Imminent Eviction • Imminent PN begins referral Deportation and follow-up process within 48 hours PN makes a plan with Social Worker/Providers on-site to address emergent needs 9
Referral and Follow-Up Process Intake interview to review Follow-Ups : PN follows up results of screen with Referrals: PN researches w/ patient every 2 weeks patient and determine community resources to to check on status of what referrals are needed address pt.’s needs, gives referral and patient’s (within 3 days after referrals to patient social needs screen) Completion Call: final PNs continue with referral phone interview to get & follow-ups for 12 Weeks feedback on patient or until patient does not experience and status of need further assistance SDH 10
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 order 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 on 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 11
Results as of October 2019 Adult Medicine Clinic Pediatric MSGO • Total screens 1,335 • Total screens 1,901 • Total screens 124 • 828 patients • 1035 patients • 65 patients screened POSITIVE screened POSITIVE screened POSITIVE for SDH needs for SDH needs for SDH needs - 279 accepted - 514 accepted - 34 accepted assistance from PN assistance from assistance from PN PN • 99 Patients referred to MLP • 66 Patients referred • 9 Patients referred to MLP - 12 cases consulting to MLP with legal team - 17 cases - 4 cases consulting consulting with with legal team Note: Screening at this site legal team Note: Screening at this site began in May 2018 began in August 2019 12
Program Successes Embedding Patient Navigators in Screening comprehensively for Clinical Workflow social needs across multiple domains Community Partners & Prioritizing Cultural Competency Medical Legal Partnership 13
THANK YOU! 14
Contact Information: Nimisha Singh nsingh60353@gmail.com 15
Recommend
More recommend
