For years, the scientific community has repeatedly demonstrated that social determinants of health significantly impact overall health more than medical care. Our Community Health team has been working with operational collaborators to implement a model that identifies and addresses social needs, and the first step is screening patients for social needs. If a patient struggles with a lack of food, housing, transportation, or utilities—even if they get the best care here at Intermountain—their overall health still depends on factors outside our clinical walls.
“If you’re taking a type of insulin that requires refrigeration and you can’t pay your electric bill, your health will still suffer despite receiving the medical care and medication needed to treat your disease,” explains Gene Smith, Community Health Director.
We launched social needs screenings in ambulatory settings and two pilot hospital emergency departments in 2018 in Utah. The screenings were done manually by clinical staff. While it was a significant cultural shift for us, screening workflows were labor-intensive and inconsistent, particularly in emergency departments where the emergency nature of patient care could make screening challenging.
In 2019, something significant happened that pushed screening to a new level. Our Medical Group began automating annual social needs screening during registration using automated screening technology that significantly augmented manual screening.
“When the automated screening technology came out in the Medical Group for digital pre-visit intake, we added the social check screening form into that workflow for primary care clinics,” Smith said. “Almost overnight, we saw annual screening rates jump to 70%. About 82% of the patients seen in clinic are now screened for social needs in Utah ambulatory sites.”
Amber Rich, the Community Health Program Manager at Intermountain Health, also shared a story about the impact of screening all patients.
A medical assistant who had known her patient—a new mom with two young kids—for 20-plus years reviewed the health screening with the patient, who had indicated a food need. While the mom was there to get treatment for her newborn, the medical assistant learned she did not have food for her toddler.
“This medical assistant would never have imagined based on knowing this young mother since she was a little girl herself,” Rich said. “It just shows that we don’t always know what’s happening in our patients’ lives. Screening was the key to awareness, and thankfully, the medical assistant could connect them to resources.”
Using automated screening technology, our Community Health team worked with the emergency department and our registration teams to automate social need screenings during registration (excluding rural hospital emergency departments). Launched in April, the implementation produced similar results; annual social needs screenings jumped from 14% to 70%.
“Asking social needs questions is just as important as getting someone’s health history or blood pressure,” Smith said. “It’s important to treat the whole person if we really want to achieve our mission.”
Our Community Health team sees screening automation as a best practice that creates more equity in awareness of social needs and, most importantly, gives caregivers valuable time and improved workflows to address social needs through connection to community resources.
These community resources are vital to our ability to provide whole-person care. We rely heavily on a wealth of community collaborations and services that provide our patients with the additional care and services needed to live their healthiest lives possible.
In 2019, our Community Health team began working with community collaborators to implement a shared technology that would allow them to make closed-loop referrals to each other securely. The benefit for clinical teams was allowing them to quickly find available resources and know whether the patients received the needed services. Collaborating with Unite Us and Utah 211, the network of community organizations has grown statewide. We are using the technology to connect patients in ambulatory and acute settings and Castell and SelectHealth care management teams are also using it to serve patients and members.
“We couldn’t do this work without our community collaborators,” said Lisa Nichols, vice president of Community Health at Intermountain Health. “We rely on their expertise and ability to connect with different populations. They have established trust in the community to lead that work, and we can support them in doing it.”