Our Social Care model is working toward health equity by identifying and addressing the individual social determinants of health that may be creating barriers for the people we serve, like food, housing, transportation, safety, and utilities. These factors impact life expectancy more than medical care and magnify health disparities in marginalized communities. It is crucial to improve upstream factors that allow everyone in our community an opportunity to achieve their full potential for physical, mental, and social well-being.
The Alliance for the Determinants of Health was a community-based demonstration that began in two Utah counties, Washington and Weber, with the objective of addressing social needs to improve health outcomes, healthcare affordability and develop a Social Care model to be shared nationwide. The best practices that emerged from the three-year initiative have become the backbone of our Social Care model of awareness, assistance, and alignment.
- Awareness begins by screening adult and pediatric patients for social needs in our hospital and clinic settings.
- Assistance is triaged based on the immediacy of reported need, acceptance of assistance, and availability of resources. Individuals are connected to available community resources and provided additional care coordination where appropriate.
- Alignment of physical, mental, and social services includes care coordination with a cross-sector of organizations through a network of community partners using a shared referral technology.
At Intermountain, we are augmenting the point of care screenings with predictive analytics. We are doing this by connecting patients—who may otherwise not frequently touch the healthcare system or are experiencing social needs since their last screening—to resources. These efforts provide a population health approach to preventive, upstream care for our patients and communities.
Coordinated Community Networks
Improving the health of one person requires a community of support. We are working alongside other community partners to strengthen coordinated community networks for physical, mental, and social services. These networks facilitate the connection of patients to community resources and improve referrals between a wide array of organizations. In several hospital areas, this includes implementing a web-based tool powered by Unite Us, which serves as the digital backbone for a Utah network of community partners called Connect Us. The shared platform allows organizations to securely send and receive referrals on behalf of the individuals they serve. In addition, it will enable organizations to track how individual needs are being met, reduces duplication of services, and quantifies community-wide disparities within services and populations.
Trauma has long-lasting and wide-ranging negative impacts on health and social outcomes. We are piloting community-based trauma-informed care initiatives to prevent and mitigate the effects of trauma. These initiatives allow us to develop best practices and learnings, then scale them throughout our organization. Our current focus is on screening patients for Intimate Partner Violence and connecting them to resources. Additionally, we’re leading efforts to develop Nurse-Family Partnerships and Pediatric Behavioral Health Learning Networks, which help build protective factors that instill resilience in patients and families.
Nutritious food is foundational to our health and well-being. Intermountain is partnering with local resources and developing internal programs to promote access to healthy and individually relevant food for patients, members, caregivers, and community members. These efforts recognize nutrition security as a necessity for the health of every life that touches our healthcare system. Nutrition is a critical factor in creating health equity and improving healthcare affordability by taking a community approach.
Making Social Care a Routine Part of Health Care
Our goal is to make Social Care as routine as taking blood pressure in assessing a patient’s health vitals. Social need screenings aim to identify patients with social needs and connect them to resources. Other intrinsic benefits to asking screening questions are just as valuable as the answers. For example, it has empowered some to seek assistance after disclosing needs. About one-third of the resolved needs in the coordinated community networks result from the patient self-resolving the issue. One patient explained the screening questions triggered a realization of how much help they needed and how long they had prolonged asking for it. Another value of screening is fostering patient-centered care. A patient who left a clinic visit without completing an annual screening for social needs received a follow-up call to ensure they did not have any needs at that time. The patient reported they were doing well and became emotional by the level of concern demonstrated for all facets of their well-being.