Because ProMedica’s screening tool is electronic, patients tend to disclose information that they may not have shared with their physician.
ProMedica’s Essential Social Needs Survey, which screens patients for hunger and other problems that can affect their health, began rolling out in its medical clinics in 2016. ProMedica plans to screen all outpatients and inpatients beginning in 2018.
“When we are fully installed across the system, we will probably be doing in excess of 1 million screens per year going forward,” says Lee Hammerling, MD, ProMedica’s chief physician executive and chief medical officer.
Patients complete the survey, which takes three to five minutes, using a computer in the exam room while waiting for the physician to arrive. Kent Bishop, MD, chief experience officer at ProMedica, comes onto the computer screen to say, “We know there are a lot of things that go on in life that make it very difficult to be healthy—food issues, family troubles, job pressures, transportation. So, today we’d like to ask you a few questions to help us get to know you better, and also link you with the resources you might be needing today.”
Patients click through several screens, answering questions about housing, social interactions, childcare, employment, and other topics. They are asked to assess their personal feelings of motivation in managing their health, such as, “It is difficult for me to take medications as instructed” and “It is difficult for me to change habits that negatively affect my quality of life.”
Using the Information
Because the screening tool is electronic, patients tend to disclose information that they may not have shared with their physician. In the first year of ProMedica’s 10-domain screening program, one patient revealed suicidal ideation.
Another screening revealed domestic abuse. “The physicians were stunned, because the patient had been in their practice for a number of years and they were unaware of these issues taking place,” Hammerling says. “These are just a couple of examples of how effective the screening tool is in helping our providers identify issues that are dramatically influencing our patients.”
When patients complete the computerized questionnaires and hit “submit,” their responses immediately flow into the electronic health record so providers have access to the information when medical appointments begin. The provider can see an overall assessment—the patient is at high, medium, or low risk for social needs—as well as responses to individual questions.
The information from the survey is used in three ways:
- Physicians can use it to discuss patients’ personal challenges in the context of their health status.
- ProMedica’s Community Care Team reviews all responses and works to address patients’ social needs.
- All data points are aggregated to assess social challenges at the community level (see exhibit).
Some physicians access patient responses and use the information immediately, while others do not, says Linda Chambers, associate vice president. “It depends on the practice and provider,” she says. “Where we’re seeing it used most often is in the practices that have a high volume of high-risk patients, because those providers see the need and they see the value.”
Patients’ response to questions about motivation help providers understand whether patients are ready to make changes that will improve their health. “If they are not motivated to change, that’s where the physicians can have some really engaging dialogue to say, ‘We know there are struggles. How can we work together? It’s not going to work without you on board,’” Chambers says.
Community Care Team
The physician is not tasked with the responsibility of addressing the issues identified when a patient is screened. Rather, each patient’s survey responses are sent to a Community Care Team, which works to help patients connect with the appropriate resources.
In addition to ProMedica’s own resources, such as the Financial Opportunity Center and in-house food clinic, members of the care team help patients find community resources. That may be emergency shelter for a homeless person, utility assistance to keep someone from becoming homeless, or a host of other supportive services.
“We know that we cannot address all these issues solely on our own,” Chambers says. “We are developing a strong community network to support these patients and have our community resources be part of the solution.”
The Community Care team includes:
- Two master’s level social workers
- Two master’s level registered nurses with community education experience
- Three certified community health workers
As the screening tool spreads to more clinic locations, the care team will grow. “We know that as we roll this out, we’re going to need more resources,” Chambers says.
The Community Care team is supported by the ProMedica Home Health Care team of 12 home care social workers whose main responsibility is to address patients’ social needs after a hospitalization. If a screening identifies that a patient’s personal safety is at risk because of domestic violence or a patient may be at risk of suicide, a member of the team makes a home visit to do a comprehensive assessment. “They will make follow-up home visits and phone calls, depending on the patient and the circumstances, to ensure that issues are resolved,” she says.
The identified issues and resolutions are entered in the patient’s electronic medical record so physicians are kept apprised.
“While they don’t have to resolve a patient’s housing need, as an example, we do want our providers to be aware of the issues that are happening with their patients and how we are able to resolve them,” says Kate Sommerfeld, ProMedica’s president of social determinants of health.
Tips for Success
Currently, ProMedica conducts the screenings in the exam room, attempting to make use of the waiting time between when the patient is roomed and when the physician arrives for the exam. The PC used by members of the care team is configured to allow patients to use the screening tool but not to access browsers, medical records, or any other content or functionality.
Some physicians have complained that conducting the screenings in the exam room slows patient throughput. Consequently, within the next few months, the screening tool will be made available to patients in three ways:
- On a tablet, which patients will access before or after a doctor’s appointment
- Via a patient portal component of the electronic health record system
- Via a link sent to the patient by email in conjunction with an appointment reminder
Other advice from the front lines:
Recruit physician champions. While most physicians and other providers recognize the importance of social determinants of health, talking about them with patients and helping patients address their non-clinical needs is new territory for many clinicians. That’s why having physicians who are willing to promote a social-determinants initiative to their colleagues is a success factor, Chambers says.
Training is key. ProMedica developed training programs for medical assistants, front-office staff, physicians, and system leaders to educate them about why screenings for social determinants are important and how the screening initiative works.
Create the right screening tool for your population. When ProMedica started screening for food insecurity in 2014, it used the Hunger Vital Sign, a two-question screening tool based on the U.S. Household Food Security Scale. As it prepared to screen for other issues, a steering committee was convened to identify clinically validated questions about a wide variety of social factors that affect health. The right issues to screen for varies from one community to the next, based on local factors, Chambers says.
ProMedica worked with other national organizations that have addressed the social challenges of their patients, to learn from their experience. “We put together a pretty vast spreadsheet of the various questions that have been clinically validated in each of the domains and our steering committee helped us pick the best ones for our population,” Chambers says.
See related article: Addressing Social Determinants of Health
Interviewed for this article:
Linda Chambers is associate vice president, ProMedica, Toledo.
Lee Hammerling, MD, is chief physician executive and chief medical officer, ProMedica, Toledo.
Kate Sommerfeld is president of social determinants of health, ProMedica, Toledo.