Home Icon
Search Icon

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

Project Final Report (PDF, 700.28 KB) Disclaimer

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 -
Completed

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.

Low-Cost Screening in the Emergency Department Helps Address Social Determinants of Health

Low-Cost Screening in the Emergency Department Helps Address Social Determinants of Health

The use of an emergency department referral infrastructure that includes an electronic assessment of patients’ social needs (e.g., transportation, food, and housing assistance) can facilitate referrals for those in need and help with monitoring patients post-discharge.

Principal Investigator: Wallace, Andrea
Organization: University of Utah
Research Profile: From Emergency to Community: Implementing a Social Needs Assessment and Referral Infrastructure Using Health Information Technology
Funded Amount: $299,620

People’s life circumstances affect their health and quality of life

Social determinants of health (SDoH), such as a patient's education, income level, and environment, have a major impact on health outcomes, especially for the most vulnerable populations. Addressing inequities in SDoH can help eliminate health disparities, can improve individual and population health, and should be considered when providing treatment and care. However, questions remain about the best way to collect these data during visits and—more importantly—how to screen and address for social needs during appointments with patients.

Emergency departments (EDs) are currently the only locations within the United States’ healthcare system where patients cannot be turned away due to an inability to pay. Consequently, many low-income and uninsured patients are seen in EDs, making them optimal settings for social needs screening. Providers have expressed concerns about how best to integrate this screening into clinical care. Many providers have also found that they do not fully understand the impact of social needs on their patients and how to connect patients to needed nonclinical resources. To address these challenges, Dr. Andrea Wallace decided to study how to develop an effective, sustainable method for integrating both social needs assessment and referrals into routine ED care delivery.

As a clinical nurse specialist, I focused on chronic illness management in primary care, but I saw a lot of patients with various social determinants of health. I became acutely aware that we can only do so much in our clinical settings. What happens after people go home, or wherever they're going, is what determines their health outcomes. I could put people on the most perfect medication regimen, but it does not matter if they can't integrate taking medications into the context of their lives. I was very passionate about health disparities early on and was introduced to how factors such as health literacy, race, ethnicity, language, geography, and social connectedness affect how different populations access care.”
–Dr. Wallace

Developing and integrating a social needs screener into ED workflow

Dr. Wallace and her University of Utah-based research team, which includes community partners, developed a 10-item electronic social needs screener, using low-cost technology that was integrated into the ED workflow. Patients who indicated that they had unmet needs and who wished to receive assistance were directly referred to the United Way of Utah’s 211 service by ED registration staff. This 211 service provides a free, comprehensive list of contact information for local resource providers who address common social needs (e.g., transportation, financial advice, food and housing assistance, etc.). Trained specialists staff this phone line 24 hours per day, 7 days a week and have access to an information pool of over 10,000 services in Utah and the surrounding States.

By putting a standardized process in place for all ED patients, the team wanted to address any stigma involved with the screening, as well as take out the “guess work” of who needed to be screened. The team found that patients were more comfortable when they knew all patients were being asked questions for the purpose of service referrals, rather than perceiving that they were identified for screening because of how they look, their race, or their insurance status. Following the social needs screening, while also tapping into the multiple resources available through the United Way’s 211 service, the ED staff has been able to facilitate referrals to appropriate services for a larger number of patients.

Making an impact on patients’ lives

From the screener, the team found that there are four primary drivers—food, housing, utilities, and household items—as to why patients wanted referrals. The 211 specialists contacted these patients at least twice to coordinate referrals, but ultimately it was up to the patient to engage with the specialist and access the referrals. Although only a small subset of patients with reported social needs received community-based services, the team was successful in identifying and addressing these patients’ social needs.

Our 211 specialist spoke with a 64-year-old man who mentioned that his health has been getting better but needed Information on how to apply for food stamps. Our specialist was able to connect him with Communidades Unidas, to have someone assist him with filling out an application. After 2 weeks, our specialist checked in with the gentleman, and he will be receiving food stamp benefits each month. He mentioned that he doesn't need any other resources and will follow up with Communidades Unidas for additional help.”
– Staff Testimonial

Dr. Wallace and her team demonstrated that existing, low-cost, and readily available technology can integrate social needs screening successfully into ED discharge processes. The technology also makes direct referral to expert community resource specialists who are part of a nationwide system. The team also successfully integrated the social needs screening and referrals as part of symptom monitoring after COVID-19 testing via an electronic health record’s patient portal, showing that the screening has been easily adopted into COVID-19 testing. Finally, this approach has become a cost-effective way for the team to better understand and address all patients’ social needs and health disparities.