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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;
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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
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Assessing Social Determinants of Health: Collecting and Responding to Data in the Primary Care Setting
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Montefiore Key Facts
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Rationale for Social Determinants of Health Screening
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Structuring SDOH Screening
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Building a Tiered System
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Screening Tool Selection
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6 SDOH Workflow Considerations
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Analyzing Provider Workflow Models
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SDOH Positivity Results
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7 Challenges and Considerations
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6 Key Next Steps
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NowPow Referral Tool
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Evaluation and Recommendations
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Q&A: Ask the Expert
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SDOH Support Tools
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Post-Screening Patient Engagement
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ICD-10 Codes and SDOH Resolution
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When Providers Lack SDOH Resources
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Universal vs. Targeted SDOH Screening
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Financing at Outpatient Sites
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Glossary
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For More Information
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About the Contributor
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