Social Determinants of Health Assessment Launches in Inpatient Areas

November 18, 2021 | 2 min. to read

On November 8, a new program to gauge individual social determinants of health (SDOH) launched in all inpatient areas across Northwestern Medicine. The goal of the program is to screen inpatients for a concise set of SDOH that act as barriers to health, and ask patients if they want to be connected with resources that can help them address those needs.

Earlier in 2021, the SDOH program was piloted at 15 sites in primary care, inpatient and emergency department settings, across diverse geographical regions. Since April, more than 12,000 patients have been screened using the new process. Of these patients, about 10% requested referrals to help them navigate SDOH needs.

“The SDOH project goes along with our Patients First value, treating the whole patient and setting them up for success after discharge by providing resources they may not have known about in the past,” says Abby Falbo, director, Nursing Operations at Huntley Hospital.

SDOH are broadly defined as social and environmental factors that affect a patient’s health. The focus of the SDOH team at NM includes needs shown to be most important nationally and in the NM regions:

• Medical home (patient has a usual source of care)
• Medication affordability
• Transportation to medical appointments
• Food insecurity
• Housing instability
• Access to mental health care

Patients who identify a concern are asked if they want to learn about resources for addressing the needs. A community referral platform called NowPow generates a resource list based on the patient’s home ZIP code. NowPow is integrated with Epic, so the list is included in the patient’s After Visit Summary.

Prior to the November 8 inpatient launch, staff completed training on the new process. Nurses will include the SDOH screener in their admission workflow using the Admission Navigator. Available support tools include talking points to use with patients and tip sheets for Epic and NowPow. If you have questions about the SDOH, please contact your local Quality leader or visit the Equity NM Interactive page (login required).
 
SDOH screening and referral will soon be available in ambulatory care as well: The program begins in primary care and obstetrics and gynecology practices this winter, followed by emergency departments in spring 2022. For questions, comments and suggestions, contact [email protected].