January 7, 2022

Human connection makes each of us, and our communities, more resilient in the face of challenges like COVID-19. By talking with patients about their social circumstances, primary care providers are in a stronger position to help by making referrals or connecting their patients with other types of community services and support.

For the past year, OCHIN has been working to enhance providers’ ability to support patients over age 50 who are experiencing loneliness and social isolation during the COVID-19 pandemic by launching comprehensive screening tools and workflows at four pilot sites: Alliance Medical Center in California, Cowlitz Family Medical Center in Washington, Open Door Community Health Centers in California, and NorthLakes Community Clinic in Wisconsin. With funding from AARP Foundation, these OCHIN network members have been able to expand their health centers’ screening efforts related to social determinants of health (SDOH) to include new questions about social isolation and loneliness, or implement such social risk screening for the first time.

“The ongoing COVID pandemic has been pulling our clinic staff in so many different directions for so long,” said OCHIN Practice Coach Molly Volk. “But this project, I think, because it is focused on social isolation and loneliness, which is being exacerbated by the pandemic, has stayed at the top of a lot of staff’s minds.”

Roughly 30 percent of patients screened through the project, thus far, identified at least one risk for social isolation and loneliness, demonstrating the need for continued screening efforts paired with solutions that help connect primary health care services to behavioral care and wider community-based social support.

Streamlined Social Risk Screening Enhances Patient Care and Staff Support

Talking with patients about their social needs enables care teams to better identify the social and structural factors that influence overall wellness. Loneliness and social isolation have been shown to be an independent risk factor for premature death—rivaling the risks of high blood pressure, smoking, and obesity. Other social determinants of health (SDOH), such as inadequate access to food, safe housing, or reliable transportation, also pose significant health risks and may co-exist with social isolation and loneliness. That’s why OCHIN’s project team made a deliberate choice at the start of the AARP Foundation-funded pilot program to combine SDOH and social isolation screening questions to give providers a more complete picture of their patients’ health and well-being that would serve them in the long term.

Using OCHIN’s comprehensive screening tools, providers can now seamlessly conduct patient screenings, record their results in a standard data format, and even make referrals for social support directly from their OCHIN Epic electronic health record system (EHR) using an integrated social service resource locator (SSRL) called FindHelp (formerly known as Aunt Bertha). FindHelp is an online platform that provides connected social care for healthier communities, featuring more than 300,000 human-verified programs that provide help to millions of people across the country.

Not only does this streamlined screening and referral workflow enhance whole patient care and help improve health outcomes; it can also save over-burdened health clinics valuable staff time and resources by making it easier to connect patients directly to resources for ongoing social support that are available in their community. For example, using new tools that can place these referrals electronically, OCHIN providers have connected over 6,300 patients with non-medical assistance directly from the EHR in the last two years. And where local resources aren’t yet listed in FindHelp’s online directory, many local health centers are leading efforts to expand the platform by encouraging trusted community partners to register, so a wider variety of local resources are available for online referrals in the future.

OCHIN’s leadership in the field of standardized SDOH screening also extends beyond the pilot project’s focus on loneliness and social isolation. To date, providers across the OCHIN network have recorded more than 1 million SDOH screenings for over half a million unique patients nationally in the OCHIN Epic EHR. These screenings also include other topics, such as housing, personal safety, employment, and transportation, giving providers a wider view of the types of social support that would benefit their patients’ overall health.

Customized Screening Tools and Optimized Workflows Better Meet Community Needs

One accelerator for social screening is the support OCHIN has provided to its four pilot sites to develop custom screening tools for their providers to implement based on the localized needs of the communities they serve. In many cases, the prospect of conducting a wide-ranging screening for every patient can be daunting to providers who are already juggling full patient panels, unprecedented staff turnover, and the additional demands of ongoing COVID response and vaccination. To assist, OCHIN worked directly with each pilot site to develop customized screeners that include only the most-needed screening questions, and provided ongoing coaching and training in methods such as empathetic inquiry to help ensure screenings were conducted in a personal and trauma-informed way.

“All our member organizations care about deepening their connections to their patients,” said OCHIN Practice Coach Megan Bowen. “Some organizations are hesitant to screen because they can’t supply all those needs, and so they just don’t do it at all. Well, at OCHIN we can create a customized screening tool with just the questions that they want to ask, and once we went through that process with Alliance then things really exploded.” Within one month of full implementation, screening utilization at Alliance Medical Center grew by 400 percent, signaling what could be achieved at all four pilot sites.

OCHIN used a proven five-step implementation process that was originally developed for its ASCEND project to get each site up and running with the new screening tools. From there, ongoing check-in meetings and peer support calls have been critical to keeping staff engaged over the two-year grant cycle, despite vacations, turnover, and often competing COVID priorities. Throughout the project, OCHIN practice coaches have also helped each site optimize its clinical workflows to meet unique organizational needs, technologies, and staffing structures to help ensure success.

“When you’ve seen one implementation, you’ve seen one implementation,” Bowen said, speaking to the importance of OCHIN’s intentionally tailored approach.

Improved Screening Furthers Growth of Community Connections

Now that the new screening tools and workflows have been fully implemented, the four pilot sites are beginning to look for ways to expand their efforts. For example, NorthLakes Community Clinic is a rapidly growing organization serving nine counties in rural northern Wisconsin where health outcomes are poor and transportation challenges are a common barrier to accessing regular care. Other community support services are also limited.

“In the communities we’re in, there are not a lot of resources for people,” said Nate Roberts, Director of Community Support Programs at NorthLakes Community Clinic in Hayward. “That’s what really intrigued me about participation in this pilot. It layered really nicely with the work we’ve already been doing in our community health worker program, particularly around screening people for social determinants of health. I thought it would be an opportunity for us to make more connections for people.”

The health center has eight community health workers (CHWs) on staff who regularly conduct about 100 SDOH screenings per month across 12 clinic sites. When the pilot first launched, NorthLakes assigned one of those CHWs to test its efficacy at just one clinic site, successfully completing more than 30 screenings for social isolation through the pilot in November. Building on this growing momentum, the health center recently added a second CHW to support the pilot full time at another location and Roberts hopes to gradually scale those efforts by building the response infrastructure to support screening via MyChart and by working to normalize all types of SDOH screening among other providers, so the whole care team is engaged.

“Ideally it’s not just something that we do as CHWs,” said Roberts. “It’s something we all do as part of our workflows. Again, lots of thinking and planning needs to go into that. It’s not something we’re going to get to now, but I see that having big potential through some of the ideas that OCHIN shared with us.”

OCHIN looks forward to helping each pilot site, and other organizations across our national network, expand their use of comprehensive and integrated social risk screening tools in the coming year. In fact, a new implementation toolkit created by OCHIN and the Kaiser Permanente Center for Health Research is now available through the Social Interventions Research & Evaluation Network (SIREN), as part of this broader effort. To learn more or access the EHR-platform agnostic toolkit, please visit https://sirenetwork.ucsf.edu/guide-implementing-social-risk-screening-and-referral-making