Lessons Learned: Implementing and Expanding Social Needs Screening Programs in Health Centers - Session 3: Level 3: Responding to the Social Needs Screening

HITEQ Learning Collaborative Series

This learning collaborative presented by the HITEQ Center allowed participants to learn about health center promising practices and key considerations to support the successful collection, monitoring, and addressing of social needs data. During the series participants explored the levels of maturity in the social needs screening implementation process. Participants gained information on concrete strategies and IT solutions that will help to improve internal systems, such as EHR utilization and care team workflows, and increase their capacity to advance individual and population-level health. Health center exemplars will be showcased.

The levels of maturity include: 

• Level 1: Coming to Consensus

• Level 2: Implementing a Social Needs Screening Tool

• Level 3: Responding to Positive Screens

• Level 4: Monitoring and Using Data

Session 3: Level 3: Responding to the Social Needs Screening

During this session, participants learned about concrete digital solutions health centers can leverage to document, communicate, respond to, and track positive screens.

Topics: Documenting positive screens (order sets, Z codes, problem lists, favorites group), sensitivity with Z codes, communicating positive screens (internal referrals, telephone encounters, global alerts, castover), responding to positive screens (internal and external referrals, role of behavioral health or case management department, challenges with community-based referral platforms, tracking referrals, prioritizing positive screens.