To advance its Population Health Strategy, where ThedaCare predicts and prevents health needs and is a partner in the health and well-being of all community members, ThedaCare is using a new social determinants of health (SDOH) screening tool to identify social needs and connect patients who are struggling with resources. ThedaCare Physicians Internal Medicine-Neenah is the pilot location for the screenings which began on April 19, 2021.
“Social and economic determinants of health, such as income, housing and social supports account for about 40% of an individual’s overall health,” said Paula Morgen, ThedaCare director of community health and co-leader of the SDOH Initiative. “Caring for social needs, along with medical needs, is a key component of our Population Health strategy. For example, when someone goes from being homeless to being affordably and safely housed, primary care visits increase 18%, while ED visits decrease 20%. That’s Population Health,” said Morgen.
Patients visiting sites will receive a notification in their MyThedaCare/MyChart account approximately seven days prior to their appointment requesting they complete the Social Determinants of Health Screening, which is a series of questions about food insecurity, financial strain, transportation and housing. Based on their answers, a color-coded wheel populates in the EMR to help providers understand the social needs of a patient, whether they’re doing well, may need some assistance or need critical assistance. Patients at moderate or high risk are connected with community resources by a navigator who follows up to increase the chances that patients receive the help they need. Patients can also participate in the screening at check-in or during their appointment. Soon, a complete database of community resources from Wisconsin 2-1-1 will be downloaded into Epic to ensure patient options are readily available for referral.
The annual screenings for those 18+ are confidential and adhere to HIPAA privacy rules. Patients may decline the screening opportunity.
“Our goal is to treat the whole person and go upstream to improve outcomes. We appreciate our many community partnerships to accelerate our work in Community and
Population Health, and help our patients live their best lives," said Tara Anderson, co-leader of the SDOH project and manager of care management. "We will explore expanding the social determinants of health screening to other ThedaCare locations in the future.”