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

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From Emergency to Community: Implementing a Social Needs Assessment and Referral Infrastructure Using Health Information Technology - Final Report

Citation:
Wallace A. From Emergency to Community: Implementing a Social Needs Assessment and Referral Infrastructure Using Health Information Technology - Final Report. (Prepared by the University of Utah under Grant No. R21 HS026505). Rockville, MD: Agency for Healthcare Research and Quality, 2020. (PDF, 700.28 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison).
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The use of an emergency department referral infrastructure including an electronic assessment of patients’ social needs (e.g., transportation, food, and housing assistance) can facilitate referrals for those in need and monitor population health post-discharge, which shows the potential of such infrastructure to improve health outcomes and reduce inappropriate emergency department usage.

Project Details - Ended

Summary:

Assessing social determinants of health needs, such as transportation, food, and housing assistance, has the potential to improve overall health and wellness. Low-income under- and uninsured individuals have high rates of unmet needs, contributing to poorer health outcomes. This population has a higher rate of emergency department (ED) utilization, contributing to high healthcare costs for non-emergency care. Screening these patients and referring them for needed social services has the potential to reduce inappropriate ED usage. This research team developed a 10-item electronic social needs screener that was integrated into the ED workflow. By partnering with the United Way’s 211 service, a free nationwide program with linkages to local resource providers, the process better identified those in need and facilitated referrals to appropriate services.

The specific aims of the research were as follows:

  • Evaluate the technical and operational feasibility and acceptability of implementing a health IT-delivered social needs assessment and referral process during routine ED service delivery. 
  • Obtain preliminary estimates of effectiveness of health IT integration of social needs and community-based referral data within the health system. 

ED staff guided patients through the screener questions, referring those with a positive screen to the 211 service, so that the service could facilitate appropriate referrals to community-based resources. The 211 service staff had access to the screener results, contacted interested patients within 48 hours to facilitate referrals, and followed up within 7 days to determine follow through. Evaluation of the process was completed by examining referral data from the 211 system and health outcomes from the hospital’s electronic health record, identifying patterns in the nature, quality, and usefulness of the intervention. Qualitative interviews of ED staff and focus groups of patients were conducted to explore approaches to screener delivery, attitudes toward clinical utility, patient value, and overall acceptability, as well as benefits of and barriers to the social needs screening and referral process.

The screener did not represent significant technological, time, or cost barriers to implementation. Qualitative data from both staff and patients suggested that the screening and referral process changed how care was provided and increased knowledge of patients’ social determinants of health. Although few patients with reported social needs ultimately received community-based service referrals, this research highlights the feasibility of integrating social needs screening into ED discharge planning and the importance of partnering with an existing nationwide system of community resource specialists.