Sarah, a disabled patient and community member in southern Utah, recently went to a routine checkup at Intermountain’s River Road Internal Medicine clinic. Beyond getting support for immediate health needs during her visit, Sarah left with a referral to resources that could help pay her utility bills.
“The healthcare evidence is clear: factors beyond access to healthcare affect our longevity and quality of life,” says Sarah’s internal medicine doctor, Tyler Haberle, MD. “We call these factors the social determinants of health, and by addressing these social determinants, we can provide better, more inclusive care.”
Intermountain has developed a social care approach that can be used to help address patients’ social determinants of health. The social care model includes screening patients for potential needs and then connecting patients with the resources that can help.
“Our Intermountain Social Care Model aims to elevate 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,” says Community Health Director Gene Smith. “Social determinants impact life expectancy more than medical care and magnify health disparities in marginalized communities. So when we improve environments, everyone in our community improves their potential for physical, mental, and social well-being.”
We’ve also begun to automate our social care model in several ways, including using built-in iCentra decision support. This automation came into play during Sarah’s visit.
Sarah has recently experienced challenges paying for housing expenses, a concern she indicated when responding to her pre-visit request to check in and complete forms sent by Intermountain’s information gathering partner, Notable. The pre-visit forms she completed included Social Check, Intermountain’s social needs screening tool.
“Our medical assistant saw the iCentra SmartZone alert of the newly stated need,” Dr. Harberle says. “She discussed with Sarah the opportunity to be referred to assistance resources, but Sarah declined the referral. Our medical assistant advised me of the situation as I entered the room. As we began reviewing her conditions, I was reminded by iCentra to circle back to the Social Check need and discuss it with her.”
The iCentra alert prompted Dr. Haberle to discuss social support needs with Sarah.
“After a brief conversation about the why behind our questionnaire, and our mission to help her afford her medications and live the healthiest life possible, she consented to the referral ,” Dr. Haberle says. “Using the Unite Us digital social care referral platform, the medical assistant connected Sarah to resources for assistance paying her utilities.”
“We’re thrilled to hear Sarah and others’ social needs are being discussed and addressed,” Gene says. “Automating our social care model wherever possible will help us eliminate disparities and create opportunities for caregivers, patients, members, and communities to thrive in profound ways.”
“Informatics solutions like iCentra decision support help remove barriers to obtaining consent and refer patients to needed resources by keeping their needs top-of-mind,” says Dr. Haberle. “I’m a proponent of social care and grateful for the work our informatics team, including Clinical Informatics managers Lesly Goff, Michelle Palmer, and Jacob Tripp, have led in designing, implementing, and supporting Social Check, Notable, and SmartZone alerts. We’re making these tools available to Intermountain’s clinical caregivers to improve relationships with patients and engage in vital conversations about social determinants that can help them live healthy lives.”
How you can get involved? This work supports the core of health and our mission. Watch for alerts and screening results if you are a medical assistant, provider, APP, or social worker. As you help patients feel comfortable engaging in conversations that can help them live their healthiest lives, you can normalize this more inclusive approach to care.
Learn more about Intermountain’s Social Care model.