Decreased access to stable housing, healthy foods and social connections increases the likelihood of becoming sick, and hospital readmissions, among other health outcomes. UW Health has an aspirational goal to ensure that all patients will be screened for social determinants of health (SDOH) and receive appropriate follow-up in a patient-centered, trauma-informed and culturally responsive manner. UW Health has embarked on a multi-year initiative to standardize the use of SDOH screening and resource referral. They are ensuring that in addition to standardized screening and use of electronic medical record tools, there is the capacity to respond with community resources and care team supports.
This year, as a part of UW Health’s partnership with the Dane County Health Council to address disparities in Black low birthweight and infant mortality, they will be participating in the development of a county-wide care coordination system utilizing tools within the electronic medical record to have two-way communication with community-based organizations for our pregnant patients. This project, ConnectRx, is part of their community health needs assessment priorities to address disparities in Black low birthweight and infant mortality. Project planning is underway to launch this initiative for pregnant patients by the end of 2021.