Care Management Aided by Solutions to Social Determinants of Health Needs
By Melinda Young
Health systems can help patients overcome obstacles to maintaining their health by focusing on screening for social determinants of health and developing solutions to their chief challenges.
- One healthcare organization gives emergency food bags to patients in ambulatory settings, as well as those in the emergency department or during discharge.
- Another solution is to provide concierge transportation services to take patients to their clinic visits or to send them home after a hospital stay.
- Housing often is an issue for hospitalized patients. One solution is to provide temporary housing. Patients can stay there while recuperating from surgery or their hospital stay.
When a healthcare system asked clinical staff in all settings to screen patients for social determinants of health (SDOH), patients’ personal struggles became apparent. The next step was more of a challenge — developing solutions.
The organization focused on temporary solutions that would benefit the health system as well as patients. These efforts are aimed at reducing non-emergency trips to the ED and no-shows at ambulatory clinic appointments.
“In our practices in the ambulatory space, we screen for social determinants of health at our e-check-in,” says Kimberly Bahata, MBA, RN, CCM, BSN, administrator for ambulatory clinical care at WellSpan Health/WellSpan Medical Group in York, PA. “We prioritize food, housing, and transportation because those are the three elements that most closely align with the care our patients will receive in our medical practice. When a patient comes in and says they have food insecurity, we ask, ‘Do you have food in your home today?’” If the patient does not have access to food, then the office’s staff will give the person an emergency food bag.
Solutions to patients’ most common social determinants of health needs came about because the organization was screening for SDOH and had increased its screening rates since 2017. “Patients were letting us know when they were having challenges, but we needed to develop a mechanism for that urgent connection point. That’s why we provide food support and transportation for patients in need,” Bahata adds.
Screening for SDOH helps a health system provide care more effectively and efficiently. For instance, if patients indicate problems with affording their medications, it makes no sense to prescribe them drugs they will not fill because of affordability barriers. “We want to make sure we’re supporting our patients in the right way and we’re addressing their hierarchy of needs,” Bahata says.
The organization first introduced the SDOH screening with clinical staff and pushed more consistent use of the SDOH questions during the COVID-19 pandemic, when more patients appeared to be lacking access to food.
“We had a greater uptake in 2020 of asking the questions,” Bahata recalls. “We had a nurse practitioner and physician on our team of social determinants of health engagement, and we engaged providers to use these as part of the treatment plan.”
When the organization switched to electronic check-ins during the pandemic, they saw more patients who admitted to concerns about food and housing. They were willing to admit to their issues through the electronic questionnaire.
“We made referrals based on their needs, but we kept hearing from caregivers that they wanted something they could hand to their patients right here — beyond the referral to a food bank,” Bahata says. “They have that food bag now to hand to the patient.” The program is an extension of case management with inpatient case management, ambulatory case management, and other partners working as one in their communities, she notes.
WellSpan implemented these SDOH solutions:
• Food insecurity. Patients with hunger issues receive emergency food bags at discharge from an inpatient stay and after leaving the ED. Also, providers at primary care practices, pediatric practices, and urgent care centers keep emergency food bags in stock. The program started in July 2023.
“Our emergency bags have enough food for one person for one day,” says Missie Dehoff, LPN, clinical manager of operations in the Women and Children’s Service Line at WellSpan Health/WellSpan Medical Group.
A grant helped fund the program, which provides a brown paper bag full of enough food to feed one person for one day, Dehoff explains. The bags contain cereal, milk that does not require refrigeration, fruit cups, applesauce, a water bottle, and a packet with a vegetarian or chicken meal that can be eaten as it is or heated in a microwave.
“Nothing in there has to be refrigerated,” Dehoff says. “When something is going to expire, we replace the item.”
The food bags have been popular with patients. “We had one patient who asked if they could open the bag now because they hadn’t eaten in quite some time,” Dehoff says.
The bags were designed to be discreet. No one viewing them would know they contained food support. This has proven helpful in obtaining patient acceptance of the help. “We had an incidence where a mother was with three children at the pediatrician’s office, and she declined the food initially,” Dehoff explains. “Someone brought back a bag to show her that it was a plain brown paper bag with nothing on it other than a colored sticker that indicates whether it’s vegetarian or contains chicken.” Seeing this, the mother decided to accept bags for herself and her family.
Typically, offices have between three and five bags in stock. They can be replaced on the same day if needed. “Usually, if they get down to one or two bags, they reach out to me or our clinical manager,” Dehoff explains. “Most of the managers of clinical staff are willing to work with us and go pick up items, or I’ve met some people halfway.”
People work together to keep this service available, and they would like to expand it, Dehoff notes.
• Transportation. “We want to ensure patients can get to us for those urgent/emergent needs instead of calling 911 and taking an ambulance for a low-level visit,” Bahata says. “If a patient says they have no transportation and are scheduled for a visit, all of our practices have access to a concierge [transportation] service. We set it up electronically and monitor it, and it’s decreased our no-show rate.”
The transportation service can drive patients to and from a provider’s office and home from the hospital or ED. “Maybe a family member could drop them off and then had to get to work, and so we would see the patient and get them home,” Bahata says. “All the practices have this at their fingertips.”
Patients who indicate in registration that transportation is a barrier are connected with the concierge transportation service. “The focus is on urgent or emergency visits — not for routine transportation instead of a bus route,” Bahata explains. “If they say the buses are not running, or their ankle is sprained, we could deploy it. The patients are good about when they use it and not use it.”
Patients who need to return for a procedure can use the service. It also is used by patients who lack transportation to their primary care providers and may end up in the ED for health problems that could have been prevented.
Providing the concierge transportation service has helped WellSpan reduce the percentage of no-show patients where transportation was the reason for missing the appointment. One ride even involved taking a patient to another city, 45 minutes away, to see a specialist, Bahata says.
Internal data showed a 25% decrease in no-shows in the last month. “We average 150 to 170 rides per month, across six to seven counties in our health system,” Bahata adds.
The transportation service is paid through WellSpan Health operational dollars. It started in March 2023 as part of a one-year program to study how the service worked to help patients with their transportation SDOH and to help reduce no-show provider appointments.
“Our plan of attack was to do a full year of this program to quantify the needs and to see what the impact would be,” Bahata says. “That’s the approach we took, and we have some really good feedback from some of our patients.”
• Housing. WellSpan employs an Arches to Wellness recuperative care program that provides housing while patients are healing. The program gives people experiencing homelessness a short-term place to stay while they heal.1
“It is a personal care facility that home health staff go into, and it’s for patients who need temporary housing,” Bahata says. “We have beds to help patients get medical services in a safe environment before transitioning [to] whatever home setting they may have.”
The temporary housing is part of the organization’s partnership with community facilities. They employ an administrator and someone who will help people with medication management. Home health professionals visit patients in the temporary housing, just as they would visit people at their own homes.
“It’s a group home with a number of people — maybe six to 12 — living in one house together,” Dehoff explains.
After the temporary stay, patients who are stable transition back to a shelter or wherever else they had been before their medical issue.
Through care management, the ambulatory team identifies resources for longer-term support. They make referrals and connections. “We have a robust ambulatory care management structure,” Bahata says. “They’ll make referrals and connections and have amazing community organizations that work on intake and can assure you where the person is going next.”
Focusing on SDOH in the future may include starting a long-term program with the food bags and expanding to other service lines. “I’d like to work with public transportation and social services agencies,” Bahata says. “I’d like to use this more broadly in community engagement, and I would like to bring back patients who used the food bag program and transportation program and have them tell their stories.”
- WellSpan Health. Recuperative care and housing. 2023.
When a healthcare system asked clinical staff in all settings to screen patients for social determinants of health, patients’ personal struggles became apparent. The next step was more of a challenge — developing solutions.
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