Social Determinants of Health Pilot Launches

May 27, 2021 | 1 min. to read

Data suggests that approximately 68% of all adults in the U.S. have at least one unmet social need that can prevent them from maintaining their health or accessing care. Northwestern Medicine has launched a Social Determinants of Health pilot program in several inpatient, ambulatory and emergency departments with the goal of assessing all patients for a concise set of social determinants of health and connecting patients in need to resources. The project is an NM Key Initiative for FY21.

Patients will be invited to complete a brief assessment of needs in the following areas:

• Access to a medical home (usual source of care)
• Ability to afford medication
• Transportation to appointments
• Mental health
• Access to food, housing and social support

When needs are identified, patients will be offered referrals to local community resources from a comprehensive online database.

By connecting patients with community resources based on their needs, care teams can help patients improve their access to health care and their overall health. The program will be evaluated based on ability to assist patients and improve access and quality metrics, as well as usability by the clinical staff.

All Epic users will see the new Social Determinants indicator in the patient Storyboard. For now, only pilot sites are implementing the patient assessment and referral tools. Full system implementation is tentatively planned for later this year.

Outpatient pilot sites                         
·       Aurora Family Medicine
·       Grayslake Family Medicine
·       General Internal Medicine and Geriatrics, Galter 18
·       Innovative Primary Care Naperville
·       Waterman Primary Care
·       Prentice Ambulatory Clinic
·       Transitional Care Clinic, Arkes 20
·       Marianjoy Regional Medical Group Clinic – Physical Medicine and Rehabilitation
 
Inpatient pilot sites 
·       Huntley Hospital Medical Telemetry
·       Northwestern Memorial Hospital, Feinberg 14E and 16E
 
Emergency department pilot sites
·       Grayslake Emergency Center
·       Lake Forest Hospital
·       Northwestern Memorial Hospital

Please refer to this Staff FAQ for more information.