Community Referral: Using Social Determinants of Health Data & Technology Tools to Connect with Appropriate Community Resources

We asked the questions, now what? Updated in December 2018

Download full case study at the bottom of the page.

The collection of data related to patients' non-medical needs (such as transportation, housing, food security, safety, etc.) through use of Social Determinant of Health (SDoH) assessment tools (e.g., NACHC’s PRAPARE, AAFP’s The EveryONE Project), can accelerate systemic population health improvement, as well as engage individual patients in addressing those needs through coordinated access to appropriate services or community-based supports. 

According to a 2017 American Academy of Family Physicians (AAFP) survey, 83% of respondents agreed that family physicians should identify and help with social determinants of health. Research from Kaiser Permanente suggests that, of those patients screened for social determinants of health, approximately two-thirds needed some services. PRAPARE pilot data from participating health centers identified housing, utilities, and food as the most frequently identified needs. Unfortunately, 80% of the family physicians surveyed by AAFP responded that they don’t have time to discuss social determinants of health with patients and more than half feel unable to provide their patients with solutions.  So, tools are needed to help providers meet these newly identified needs, with existing resources. A number of these tools are profiled in the resource available for free download below.

Much like other screenings that are embedded in the regular workflow and used to assess the risk or severity of the patient's condition, such as the PHQ-9, Social Determinants of Health assessment tools like PRAPARE are designed to operate similarly.

Identifying level of risk or need among patients screened for social determinants of health in order to strategize responses is generally done with "risk scoring'. Here are two examples:

• SDoH only: A health center could assign 1 point per .
• Multiple sources: A health center could assign points based on number of chronic conditions, medications, ED visits in the last 12 months, and SDoH, as discussed in this HITEQ population health presentation.

Whatever approach is taken, it is important to look at the distribution of risk scores or need levels across the patient population to ensure reasonable proportions identified as high, moderate, and low. Note that Care Management, Competency A in the PCMH 2017 standards is concerned with this.

In this resource (download below!), we focus on what technology tools exist to address social non-medical needs identified through screening. For those patients with high need, the standard response is likely to be health center-based and intensive. For example, patients with high need may be provided with 1) intensive case management, social workers, and referral coordinators; 2) direct assistance with connecting to resources; 3) follow up with external providers; and 4) regular in-person follow-up visits. This is likely to take up the majority of available staff capacity.

However, gathering social determinants of health information may also point to other needs among patients with more moderate needs or in a broader array of areas (such as paying utilities or legal services). Given staff capacity and resource limitations, as well as patient preferences, those patients may require another way to be connected with appropriate community resources. It is important that any approaches used allow for tracking and follow-up, as well as provide information about community service capacity.

The tools in the case study below (including Aunt Bertha, Now Pow, and 211 Community Information Exchange) support this process by facilitating connection with community resources and needed follow-up, partially answering the question We collected social determinant of health data, now what do we do?

Download the resource below for full case studies and lessons learned from using Aunt Bertha, 211 Community Information Exchange, and other new tools for connecting patients with community resources!