From Emergency to Community: Implementing a Social Needs Assessment and Referral Infrastructure Using Health Information Technology (Utah)

Project Details - Ongoing

Project Categories


Emergency Departments (EDs) serve a disproportionate share of low-income and uninsured patients, providing an opportunity to meaningfully assess and address social characteristics associated with poor health outcomes, including homelessness, financial struggle, lack of insurance, and lack of routine healthcare. However, incorporating social needs screening into routine care without sufficient access to referral information and resources creates risks related to stigmatization, privacy, and compromising therapeutic relationships. Mechanisms are required to connect and refer patients seen in the ED to community-based service providers.

This project will implement universal social needs assessment during routine ED care and evaluate the impact of addressing these needs on population health. The research team previously developed the assessment and demonstrated the feasibility of identifying patients with social needs. The objective of the current project is to directly link identified patients to the United Way of Salt Lake’s 211 referral system. Additionally, information from the screening and clinical information extracted from the electronic medical record will be provided through the referral system. Mixed methods will be used to evaluate usage of referral services by patients discharged from the ED, patient and clinician perceptions of the system, and the effectiveness of linking social needs assessment and community-based referrals with health outcomes data.

The specific aims of this project are as follows:

  • To evaluate the technical and operational feasibility and acceptability of implementing a health information technology (IT)-delivered social needs assessment and referral process during routine ED service delivery. 
  • To obtain preliminary estimates of effectiveness of health IT integration of social needs and community-based referral data within the health system. 

The results of this study will provide health systems additional information about factors placing patients at risk for poor outcomes after ED discharge, and identify whether technology can effectively integrate social needs assessment into routine health service delivery.

This project does not have any related annual summary.
This project does not have any related publication.
This project does not have any related resource.
This project does not have any related survey.
This project does not have any related project spotlight.
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.