By Patricia Peretz, MPH, and Amelia Shapiro, MBA
To create a more just and equal system of health care, hospitals across the country are expanding the use of screenings for social determinants of health (SDoH). NewYork-Presbyterian, a comprehensive, integrated academic health care system with 10 campuses and over 3.2 million patient visits annually, recently launched a SDoH screening initiative across seven emergency departments (EDs) with the goal of identifying and addressing underlying social needs in the communities it serves, along with improving health care equity.
Lessons from the SDoH screening and management initiative were published in the June/July 2023 issue of The Joint Commission Journal on Quality and Patient Safety. The report details how NewYork-Presbyterian implemented the program, its findings, and goals for the future.
Emergency Departments: Critical Access Point
While screening for SDoH happens in inpatient and outpatient areas of the hospital, the report focuses on the EDs, which are a critical access point for many of the most vulnerable patients. As part of the initiative, SDoH screening questions were standardized in seven EDs across the hospital system. Within the first five months of implementation, more than 8,000 patients were screened, of which 17% demonstrated at least one social need.
Program Launch
Before the launch, stakeholders from the EDs, outpatient and inpatient settings determined that the SDoH screenings should start with non-admitted ED patients. A key part of the rollout was also leveraging and building upon the existing Center for Community Health Navigation Patient Navigator program.
Patient navigators not only support continuity of care by connecting patients to follow-up appointments, they also build trust and provide culturally sensitive and peer-based education. For the initiative, the Dalio Center for Health Justice (which NewYork-Presbyterian founded in 2020 to better understand and address the root causes of health inequities) hired 10 new patient navigators who were integral in conducting the screenings.
Key Elements of the Program
Governance Structure
- Before the launch, leaders of the initiative established a governance workgroup with representation from departments around NewYork-Presbyterian: the Dalio Center for Health Justice, the Division of Community and Population Health, Data Analytics, and Information Technology. The workgroup was responsible for establishing a systemwide strategy for the SDoH screenings. This enabled the team to understand and document the workflow and ongoing needs, and it established transparency.
Risk-Stratification Model
- After the SDoH screening is conducted, NewYork-Presbyterian uses a risk-stratification model to determine the level of intervention, with patients who are:
- Rising-risk: Patients that had two or more ED visits in the past year and one or more social need.
- High-risk: Patients eligible for Health Home or Accountable Care Organizations, programs that work with doctors and health care providers to help coordinate care, receiving the most hands-on support.
Rising or high-risk patients are offered the option to work with a patient navigator for in-depth support. The patient navigator refers patients to CBOs, checks in weekly for four weeks, and again at two months. Patients categorized as low risk are offered a customized list of local community-based organization (CBO) resources.
Electronic Health Record Workflow
- To facilitate referrals of the most vulnerable patients to CBOs, NewYork-Presbyterian improved the electronic health record (EHR) system with a third-party community referral platform, which helps connect patients with CBOs.
Looking Ahead
Since the report was published in The Joint Commission Journal, NewYork-Presbyterian has launched a pilot program for SDoH in partnership with three large, multi-service CBOs in neighborhoods with poor health outcomes. The goal of the pilot program is to explore the benefits of a streamlined referral and follow up process for patients who are identified as rising- and high-risk.
Patients are connected by Center for Community Health Navigation Patient Navigators directly to one of the three CBOs, which in turn cater social services to fit the needs of the patient. Funding for the pilot was provided by the Dalio Center for Health Justice and is used to support dedicated team members at the partner CBOs. The team looks forward to seeing the results of this innovative model in the years to come.
Patricia Peretz, MPH, is Director of Community & Population Health Strategy and the Center for Community Health Navigation at NewYork-Presbyterian, New York. Amelia Shapiro, MBA, is Vice President of the Dalio Center for Health Justice at NewYork-Presbyterian.