Community-based providers are a critical connection point for health care in rural and medically underserved communities, where patients often face greater challenges in accessing and following up on their care. Understanding the role that social drivers of health (SDOH)—such as unstable housing, food insecurity or lack of reliable transportation—play in patients’ overall health and well-being is essential to advancing evidence-based solutions that can improve health outcomes for an entire community by addressing the needs of the whole patient.

With more than 1.6 million social risk screenings conducted to date among more than 875,000 unique patients, providers across the OCHIN network are working diligently to better measure and manage SDOH at both an individual and community level. However, they still face many systemic challenges and practical barriers to connecting their patients to the non-medical resources and support they may need to achieve their full health potential. That is why OCHIN is advocating to improve social risk screening and intervention practices through patient-centered technology, workforce development, and national SDOH standards.

“We need to modernize our approach to integrated care delivery and ultimately create new payment models that enhance providers’ ability to sustainably address the growing medical and social complexity seen in their communities,” said Jennifer Stoll, executive vice president of external affairs at OCHIN.

Integrated technology platforms that put patients first

Providers need reliable health information technology (HIT) tools and workflows that will allow them to optimize value, enhance care delivery, and scale access to essential services. One example is robust electronic health records (EHR) technology that puts patients first and addresses medical, behavioral, and social needs with ­­­adequate connectivity, interoperability, and cybersecurity. Telehealth and other digital modalities, such as remote patient monitoring and e-Consults, are also critical.

The COVID-19 pandemic demonstrated the value of integrated solutions and modernized technology for meeting patients where they are. In the OCHIN network alone, nearly 200,000 SDOH screenings have been conducted via telehealth, demonstrating the potential of virtual screening tools to support patients with social and medical risk factors who may face barriers to receiving in-person care.

More than 8,600 social service resource locator (SSRL) referrals have also been completed using OCHIN preferred technology partner tools that are integrated into OCHIN Epic, and tools like OCHIN Epic’s Compass Rose help care teams better manage and coordinate whole-patient care. However, providers nationwide need greater access to and training on these tools, and partner organizations must also be interoperable to streamline referrals and meet growing demand.

Skilled workforce development that relieves clinical burden and connects care

During a Healthcare Innovation panel discussion last fall, OCHIN explained that clinicians need clinical and workforce support that reduces burden, increases efficiency, and enhances ability for screening and follow-up. When non-medical staff such as community health workers, social workers, or medical assistants are trained to conduct screenings, physicians have more capacity to address the results.

This is why programs like OCHIN’s community health worker training program, funded through a $3 million grant from the Health Resources and Services Administration (HRSA), are so important. The program is designed to strengthen the health care workforce in Oregon by training a new cohort of 240 community health workers to improve and sustain access to whole-patient care across the state, serving as a model for other states nationally.

National standards and quality measures that drive innovation and sustainability

Adopting national digital data standards for the identification and reporting of patients’ social risk can help reduce complexity in the system, streamline clinical workflows that facilitate connection to community services, and decrease EHR training time for staff. This not only enhances ease and efficiency; it also fuels research and innovation, paving the way for sustainable and equitable delivery and payment models that drive improved outcomes for all patients and compensate providers fairly for the value, not just the volume, of care they deliver.

For years, OCHIN has led national efforts to standardize social risk data collection and develop best-practices to increase screening, referral, resolution, and reporting through seamless EHR integration. We are proud partners of the Gravity Project, a national public collaborative that develops consensus-based digital data standards to improve how information on SDOH is used and shared. And OCHIN’s practice-based research continues to advance SDOH data collection, clinical quality improvement, and new payment models by examining how social risk influences health outcomes.

In 2022 OCHIN successfully advocated for the Centers for Medicare & Medicaid Services (CMS) to adopt a social risk screening quality measure for inclusion in key Medicare payment programs for the first time. OCHIN also developed two new social risk measures related to referral and resolution (of at least one SDOH) that the National Quality Forum’s stakeholder process recommended CMS include in a voluntary quality program next year. In addition, CMS announced their intention to establish a core set of “foundational measures” across all Medicare and Medicaid programs that includes social risk quality measures.

Forging a path forward

Fragmentation of the health care system not only affects patient experience and trust; it also limits providers’ ability to connect patients to the comprehensive care and services they may need. Modernizing our tools and approaches to ensure every patient has access to whole-patient care that addresses the intersection of health and well-being is essential to advancing health equity.

Learn more: OCHIN research on social drivers of health

• Adoption of social determinants of health EHR tools by community health centers
• National data on social risk screening underscore the need for implementation research
• Variation in electronic health record documentation of social determinants of health across a national network of community health centers
• Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs
• Comparison of community-level and patient-level social risk data in a network of community health centers
• Initiating and implementing social determinants of health data collection in community health centers
• Cross-sectional associations: social risks and diabetes care quality, outcomes