June 18, 2024
Social risks, also known as adverse social drivers of health (SDOH), may increase a patient’s likelihood of having unmet social needs, such as food, housing, and transportation insecurity. Social risks and social needs can pose significant barriers to care and negatively impact patients’ health. Screening for social risks in clinical settings is a critical step toward addressing these issues.
In the 990,000 social risk screenings conducted in OCHIN Epic last year*, more than 1 in 4 patients identified a social need for which they would like assistance.
OCHIN is a national leader in accelerating the use of SDOH data to evaluate local needs, develop evidence-based solutions to overcome structural barriers, and improve health outcomes. We help our members advance social risk screening and referrals and improve the collection of SDOH data through modern HIT tools and technology, development of a 21st century workforce, and innovative payment models that support access to primary, specialty, and behavioral health care. We also drive research and policies that sustain access to whole-patient care for rural and medically underserved communities.
OCHIN facilitates a quarterly SDOH discussion on optimizing screening and referral practices, enhancing OCHIN Epic tools, and supporting peer learning at a workgroup made up of OCHIN network clinicians and staff. Molly Volk, MHS, a practice coach at OCHIN, answered a few questions about these discussions and how they help support whole-patient care through shared learning and innovation.
How does collecting social risk screening data support whole-patient care and community health?
Enhancing our members’ ability to identify health-related social needs (HRSN) through screening has a broad and multifaceted impact on patients, providers, and communities.
First, it improves individual patient care by allowing for a more holistic approach, considering both medical and social factors that affect health outcomes.
For example, OCHIN partnerships with TrueCare and Community Health Center Network (CHCN) in California have enabled providers to screen patients for Adverse Childhood Experiences (ACEs) and toxic stress—events that can take a negative toll on a person’s mental, behavioral, and physical health over time— directly from their OCHIN Epic EHR platform. These tools have been highly effective in helping providers find toxic stress early and break cycles of generational poverty, abuse, and neglect by coordinating proper counseling, behavioral health services, or community-based resources for needs like food or housing assistance.
Second, it fosters trust building between patients and their care teams and reduces provider burnout.
When care teams ask about and show concern for their patients’ lives outside the clinic, it can enhance patient-provider connection and communication. Integrated health screenings have helped OCHIN network providers deepen their patient relationships, augment whole-patient care, and improve health outcomes. They have also saved overburdened health clinics’ valuable staff time and resources by making it easier to connect patients to resources that are available in their communities. And primary care providers who perceive that their clinic has a greater capacity and enough resources to address patients’ social needs report significantly lower burnout.
Third, it enhances community health, informs health care use and costs, and supports value-based care.
Understanding and addressing social needs can help health centers contribute to the overall health and well-being of the communities they serve. It can also lead to more effective and efficient use of health care resources, potentially reducing costs. And screening for social risks aligns with value-based health care models that emphasize high-quality, cost-effective care tailored to the whole patient, incentivizing efforts to maintain patient health by addressing diverse social, behavioral, cultural, and linguistic needs.
How do SDOH Quarterly Focused Discussions help drive member learning and quality improvement?
OCHIN’s quarterly member discussions help build community partnerships and provide a focused opportunity to examine all aspects of care related to social drivers of health through team collaboration.
Community health centers and care teams employ a wide variety of methods to screen for and address health-related social needs. The SDOH Quarterly Focused Discussion aims to elevate promising practices across the OCHIN network, such as community health worker models and using empathetic inquiry to screen for social risks, so that our members can learn from each other and gain crucial insights to improve care quality and patient outcomes.
What topics are covered?
We cover a range of topics related to social drivers of health. I curate and present recommendations and resources for addressing and screening for social drivers of health, with OCHIN subject matter expert guest speakers contributing to content development and discussion. We invite members to share practices that they have found to be successful, and peer discussion is facilitated by polls and discussion questions. The audience is also invited to ask questions.
In April this year, we had the privilege of being joined by Jarene Merritt, clinical nurse manager at Mercy Care, who shared their organization’s journey to screen for and address social drivers of health. We learned so much from her about the rich history their organization has in Atlanta, the incredible work they do to support their clients’ health and social needs, and their integral role in the community.
Next month, we are excited to be joined by research and publications subject matter experts from OCHIN, as well as a member clinic guest speaker, to share about a new SDOH referral-making toolkit and how it has been applied in practice.
Our members are so inspiring, and giving them the spotlight to shine is one of the most fulfilling aspects of my job.
How does this consultative support help OCHIN network members drive health equity?
This support helps our members drive health equity by advancing health-related social risk screening and referrals, ultimately improving patient and community health outcomes through connected, whole-patient care. Our approach involves providing care teams with comprehensive and facilitative support focused on strengthening patient trust, building community partnerships, and distributing patient care across team roles.
Visit OCHIN’s website page on social risk screening and referral to learn more about OCHIN’s integrated solutions to support whole-patient health and well-being.
*OCHIN Epic EHR-based screenings conducted over the past 12 months (as of May 2024)
