Childhood Obesity Preventer

The National Health Care for the Homeless Council and the HITEQ Center hosted a free webinar on Tuesday, February 6th, 2024, from 2 – 3 pm Eastern (1 - 2 pm Central) where they taught participants how to screen for housing status and other Social Determinants of Health (SDoH) measures that can be introduced or better integrated into health center clinical workflows. Presenters shared guidance on implementing and systematizing social needs data collection in Electronic Health Records (EHRs), followed by a panel of expert health center representatives who spoke about their programs’ journeys with social needs screening programs. Participants had the opportunity to ask questions, share successes, or discuss specific challenges they faced regarding social needs screening. 

While this webinar focused on health care for the homeless (HCH) health centers, anyone involved directly in social needs screening or interested in improving screening processes was welcome to attend.

When clinical teams have information on patients' social risks (adverse social determinants of health), they can make care plan adjustments to account for those risks, e.g., by prescribing lower-cost medications. Come hear about a team that worked with stakeholders from primary care community health centers to develop a set of EHR-based tools intended to support making such adjustments in care for patients with hypertension and / or diabetes. This talk described the tool development process, results from pilot testing the tools in three clinic sites, and how the tools were revised in response to pilot process learnings.

Addressing patients’ social determinants of health via community resource referrals has historically primarily been the domain of social workers and information and referral specialists; however, community resource referral technology platforms have more recently entered the market. The process surrounding these community resource referrals and the role of technologies within it has not been fully accounted for just yet. Based on focus groups with  healthcare providers, and community organization staff and volunteers from 3 cities in Metropolitan Detroit, the process of community resource referral were described. Findings reveal a deeply "sociotechnical" process (involving interwoven social and technology-based elements). The detailed sociotechnical process revealed were discussed, along with the implications for those currently implementing community resource referrals. The importance of knowledge and skills, personal relationships, interorganizational networks, and data sources such as service directories in the referral process were discussed.

In recent years, health centers have become increasingly interested in and charged with not only addressing the health concerns of their patients, but centering and responding to patient’s social needs. According to Healthy People 2030, social needs, also known as the social determinants of health, are the conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social needs encompass the quality of and access to resources such as housing, transportation, safety, employment, food, and more. Identifying and addressing unmet social needs as part of the clinical encounter provides the opportunity to deliver higher-quality, whole-person care, advance population health, and reduce healthcare costs.

When implementing a social need screening program, it can be challenging to identify how frequently to conduct the screening with patients. Health centers may have to explore various strategies to develop a workflow that prevents appointment backups and reduces the burden on staff. This resource shares examples of strategies gleaned from interviews with health centers.

Implementing a social need screening effectively is an iterative process. Many health centers find that their approach evolves as new concerns or considerations arise. The examples in this resource, gleaned from interviews with health centers, illustrate that unique context and needs drive what works.

Establishing a social need screening program requires buy-in from both leadership and staff. This resource shares examples of strategies gleaned from interviews with health centers.

In this video, viewers will learn how People, Process and Technology should factor into a health center's social needs screening workflow

As health centers work towards providing more patient-centered and equitable care, they are increasingly adopting standardized social needs screening tools, such as PRAPARE and others, to systematically identify the challenges patients face in managing and improving their health, such as food and housing insecurity, transportation barriers, or safety concerns.  This information can be used to make impactful care planning and programmatic changes that lead to improvements in health outcomes, resource utilization, and reimbursement.  Data dashboards help analyze social determinants of health information in visual displays that deepen insights and trigger action towards addressing patient’s social needs, improving population health, and reducing inequities in care.

This webinar provided a foundational overview of social determinants of health dashboard design and presents case studies from health centers leading the way on use of social determinants of health data dashboards to build community partnerships, improve linkages to services outside the four walls of the clinic, and demonstrate the value-based impact of social needs services in improving the health, well-being, and quality of life of communities served.  One health center shared their experience building dashboards and using them in their clinic.