When clinical teams have information on patients' social risks (adverse social determinants of health), they can make care plan adjustments to account for those risks, e.g., by prescribing lower-cost medications. Come hear about a team that worked with stakeholders from primary care community health centers to develop a set of EHR-based tools intended to support making such adjustments in care for patients with hypertension and / or diabetes. This talk will describe the tool development process, results from pilot testing the tools in three clinic sites, and how the tools were revised in response to pilot process learnings.

Addressing patients’ social determinants of health via community resource referrals has historically primarily been the domain of social workers and information and referral specialists; however, community resource referral technology platforms have more recently entered the market. The process surrounding these community resource referrals and the role of technologies within it has not been fully accounted for just yet. Based on focus groups with  healthcare providers, and community organization staff and volunteers from 3 cities in Metropolitan Detroit, the process of community resource referral will be described. Findings reveal a deeply "sociotechnical" process (involving interwoven social and technology-based elements). The detailed sociotechnical process revealed will be discussed, along with the implications for those currently implementing community resource referrals. The importance of knowledge and skills, personal relationships, interorganizational networks, and data sources such as service directories in the referral process will be discussed.

In recent years, health centers have become increasingly interested in and charged with not only addressing the health concerns of their patients, but centering and responding to patient’s social needs. According to Healthy People 2030, social needs, also known as the social determinants of health, are the conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social needs encompass the quality of and access to resources such as housing, transportation, safety, employment, food, and more. Identifying and addressing unmet social needs as part of the clinical encounter provides the opportunity to deliver higher-quality, whole-person care, advance population health, and reduce healthcare costs.

When implementing a social need screening program, it can be challenging to identify how frequently to conduct the screening with patients. Health centers may have to explore various strategies to develop a workflow that prevents appointment backups and reduces the burden on staff. This resource shares examples of strategies gleaned from interviews with health centers.

Implementing a social need screening effectively is an iterative process. Many health centers find that their approach evolves as new concerns or considerations arise. The examples in this resource, gleaned from interviews with health centers, illustrate that unique context and needs drive what works.

When clinical teams have information on patients' social risks (adverse social determinants of health), they can make care plan adjustments to account for those risks, e.g., by prescribing lower-cost medications. Come hear about a team that worked with stakeholders from primary care community health centers to develop a set of EHR-based tools intended to support making such adjustments in care for patients with hypertension and / or diabetes. This talk will describe the tool development process, results from pilot testing the tools in three clinic sites, and how the tools were revised in response to pilot process learnings.

Addressing patients’ social determinants of health via community resource referrals has historically primarily been the domain of social workers and information and referral specialists; however, community resource referral technology platforms have more recently entered the market. The process surrounding these community resource referrals and the role of technologies within it has not been fully accounted for just yet. Based on focus groups with  healthcare providers, and community organization staff and volunteers from 3 cities in Metropolitan Detroit, the process of community resource referral will be described. Findings reveal a deeply "sociotechnical" process (involving interwoven social and technology-based elements). The detailed sociotechnical process revealed will be discussed, along with the implications for those currently implementing community resource referrals. The importance of knowledge and skills, personal relationships, interorganizational networks, and data sources such as service directories in the referral process will be discussed.

In recent years, health centers have become increasingly interested in and charged with not only addressing the health concerns of their patients, but centering and responding to patient’s social needs. According to Healthy People 2030, social needs, also known as the social determinants of health, are the conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social needs encompass the quality of and access to resources such as housing, transportation, safety, employment, food, and more. Identifying and addressing unmet social needs as part of the clinical encounter provides the opportunity to deliver higher-quality, whole-person care, advance population health, and reduce healthcare costs.

When implementing a social need screening program, it can be challenging to identify how frequently to conduct the screening with patients. Health centers may have to explore various strategies to develop a workflow that prevents appointment backups and reduces the burden on staff. This resource shares examples of strategies gleaned from interviews with health centers.

Implementing a social need screening effectively is an iterative process. Many health centers find that their approach evolves as new concerns or considerations arise. The examples in this resource, gleaned from interviews with health centers, illustrate that unique context and needs drive what works.

When clinical teams have information on patients' social risks (adverse social determinants of health), they can make care plan adjustments to account for those risks, e.g., by prescribing lower-cost medications. Come hear about a team that worked with stakeholders from primary care community health centers to develop a set of EHR-based tools intended to support making such adjustments in care for patients with hypertension and / or diabetes. This talk will describe the tool development process, results from pilot testing the tools in three clinic sites, and how the tools were revised in response to pilot process learnings.

Addressing patients’ social determinants of health via community resource referrals has historically primarily been the domain of social workers and information and referral specialists; however, community resource referral technology platforms have more recently entered the market. The process surrounding these community resource referrals and the role of technologies within it has not been fully accounted for just yet. Based on focus groups with  healthcare providers, and community organization staff and volunteers from 3 cities in Metropolitan Detroit, the process of community resource referral will be described. Findings reveal a deeply "sociotechnical" process (involving interwoven social and technology-based elements). The detailed sociotechnical process revealed will be discussed, along with the implications for those currently implementing community resource referrals. The importance of knowledge and skills, personal relationships, interorganizational networks, and data sources such as service directories in the referral process will be discussed.

In recent years, health centers have become increasingly interested in and charged with not only addressing the health concerns of their patients, but centering and responding to patient’s social needs. According to Healthy People 2030, social needs, also known as the social determinants of health, are the conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social needs encompass the quality of and access to resources such as housing, transportation, safety, employment, food, and more. Identifying and addressing unmet social needs as part of the clinical encounter provides the opportunity to deliver higher-quality, whole-person care, advance population health, and reduce healthcare costs.

When implementing a social need screening program, it can be challenging to identify how frequently to conduct the screening with patients. Health centers may have to explore various strategies to develop a workflow that prevents appointment backups and reduces the burden on staff. This resource shares examples of strategies gleaned from interviews with health centers.

Implementing a social need screening effectively is an iterative process. Many health centers find that their approach evolves as new concerns or considerations arise. The examples in this resource, gleaned from interviews with health centers, illustrate that unique context and needs drive what works.