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Home>Healthcare Trends
Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services
Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services
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Leveraging the experience of several physician practices already screening patients for social determinants of health (SDOH), Montefiore Health System recently rolled out a two-tiered assessment program to measure SDOH positivity in its predominantly high-risk, government-insured population.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services outlines Montefiore's approach to identifying SDOH markers such as housing, finances, healthcare access and violence that drive 85 percent of patients' well-being, and then connecting high-need individuals to community-based services.

In this 25-page resource, Amanda Parsons, MD, MBA, vice president of community and population health at Montefiore Health System, walks through her organization's SDOH initiative, from screening ramp-up to challenges and considerations to initial findings and next steps.

Dr. Parsons shares the following program elements:

  • Industry, financial and population-based considerations driving the need for SDOH assessment within Montefiore's 700,000 patients;
  • SDOH screening instrument criteria and selection, including SDOHs addressed by each tool;
  • Population SDOH risk stratification and follow-up support for patients identified as high- and lower-risk for SDOHs;
  • Physician practice guidelines for targeting and screening of populations;
  • Examples of SDOH screening implementation by physician practice;
  • Factoring of patient needs into SDOH workflow creation;
  • Recommendations for community referral support tools, including NowPow;
  • Engagement of Montefiore physicians in SDOH assessment;
  • Initial SDOH findings, program barriers and limitations;
  • Examples of engaging the community surrounding Montefiore in addressing SDOHs, including a neighborhood initiative to improve nutrition;
  • Achievements and next steps;
  • The challenges of addressing SDOHs when little reimbursement exists;
and much more.

Table of Contents

  • Assessing Social Determinants of Health: Collecting and Responding to Data in the Primary Care Setting
    • Montefiore Key Facts
    • Rationale for Social Determinants of Health Screening
    • Structuring SDOH Screening
    • Building a Tiered System
    • Screening Tool Selection
    • 6 SDOH Workflow Considerations
    • Analyzing Provider Workflow Models
    • SDOH Positivity Results
    • 7 Challenges and Considerations
    • 6 Key Next Steps
    • NowPow Referral Tool
    • Evaluation and Recommendations
  • Q&A: Ask the Expert
    • SDOH Support Tools
    • Post-Screening Patient Engagement
    • ICD-10 Codes and SDOH Resolution
    • When Providers Lack SDOH Resources
    • Universal vs. Targeted SDOH Screening
    • Financing at Outpatient Sites
  • Glossary
  • For More Information
  • About the Contributor
Publication Date: August 2017
Number of Pages: 25
ISBN 10: 1-943542-66-X (Print version); 1-943542-67-8 (PDF version)
ISBN 13: 978-1-943542-66-6 (Print version); 978-1-943542-67-3 (PDF version)
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