OSF Launches ‘Screen and Connect’ to Identify Social Risks

When a patient recently came into an OSF HealthCare rural health care clinic with stomach issues, it turns out, there was a lot more going on than just a simple stomach ache.

Physician Assistant Mandy Robinson learned from a newscreening tool that the patient was at high risk for financial, housing andfood insecurity.

“He didn’t have refrigeration and he had eaten a piece ofmeat that he knew was probably spoiled but he was so hungry and because hedidn’t have any other food in the house he chose to eat it and became ill,” sheexplained.

Under a new primary care digital screening program forsocial determinants of health, patients use iPads and are screening for 10areas of social needs including food insecurity, financial support, housing, transportation,and intimate partner violence among others. Social Determinants of Health areconditions in the places where people live, learn, work, and play that affect awide range of health risks and outcomes. In this case, Robinson says the careteam manager helped the patient avoid that kind of dilemma in the future.

“The care manager spoke to the power company on his behalfand we were also able to get him resources on food pantries in the area, so wewere able to help with that. I believe he also has an appointment to get hishearing aid test.” Robinson added, “So it’s definitely a process when we getinto the lives of these patients but every step we take is a positive outcomefor them.”

Robinson was skeptical at first of the Screen and Connectpilot. She worried about having to address all of a patient’s needs, clinicaland non-clinical, during the average 15 to 20-minute appointment.

But, Robinson says when care managers know of non-clinicalconditions they can handle patient referrals to community resources. She onlygets involved when patients really need to be convinced to receive help or whenshe’s so concerned about a patient’s welfare that she personally follows up.Robinson often finds those who she sees have multiple unmet needs and they’rerelieved to know someone can coordinate help for them outside of the medicaloffice.

“Once they realize that we care about them beyond their labnumbers that they’re more likely to open up to us and come to us with needsthat maybe they’re not sure who to go to but they know at least, we’re a goodstarting point, Robinson shared.

The OSF Innovation team worked with OSF Medical Groupdoctors and other care team members during the pilot in a rural community tocome up with a screening tool and work-flow that would make it easy to accessdata and know more about the challenges their patients face in achieving betterhealth.

OSF Innovation rolled out the Screen and Connect tool threemonths ago and recently hit a milestone on November 5, 2019, when the 1,000thpatient was screened.  Dr. Sarah Stewartde Ramirez, vice president and chief medical for OSF Innovation, says the ideawas to treat social determinants of health like a vital sign. The team wasempowered through a design process utilizing multiple tests of change tooptimize the solution for providers and patients.  Providers desired an approach which informedtheir interactions but didn’t take up their patient-provider time withscreening questions or create delays in getting patients to rooms.

They also didn’t want the long delays typically experiencedby paper surveys or asynchronous screening, where patients screen at one time,and results are later tabulated and only inform subsequent referrals to socialwork etc. On the other hand, patients wanted privacy to share their informationand decide if they felt comfortable talking about it, so they didn’t want to becalled ahead of time or even asked face-to-face. The resulting process was ableto use digital screening to achieve the privacy requirements of patients, andthe real time need of providers to address social needs as they wereidentified.

Knowing many older patients use iPads to connect with theirkids and grandchildren, using them seemed like a great approach.

According to Stewart de Ramirez, “For discrete assessment of all 10 domains of the social determinants of health, iPads were used with every patient, every time they came into the clinic. The responses populated those social needs on food insecurity, housing, (and) transportation. As they answered those questions in real time, that information would be available to the clinician before the patient was even in the room.”

“Instead of just asking about medications related to heartfailure, medications related to their diabetes, instead of just talking aboutthe clinical needs, they could now expand to whole person needs and be able tothink about what else needs to be addressed to optimize the whole health ofthat individual and their family,” according to Stewart de Ramirez.

The iPad screening tool takes patients an average oftwo-and-a-half minutes to complete and most patients have been willing to fillout the quick screening assessment, sometimes with the help of a medical officeassistant. Nearly 40 percent of patients screened as having at least one socialrisk and nearly 25 percent have two to three social challenges that need to beaddressed. While most health care leaders believed transportation would be thenumber one challenge in rural areas, food insecurity has been the leadingconcern of patients who screened high risk, accounting for nearly one third ofpatients with a factor influencing their health outside of the medical office.

Sarah Overton, chief nursing officer for OSF Multi SpecialtyServices says results so far have prompted care teams to consider alternativeapproaches with some patients.

“It really makes them stop and think when they’re going toprescribe a medication or treatment, if it’s really the best solution for thatpatient,” she said. “Perhaps there’s a cheaper alternative or there are someresources they can connect them with that really will allow them to achievethose goals of great care overall and a great health outcome for them.”

Stewart de Ramirez says Screen and Connect has alreadyrevealed that in the bread basket of America, which feeds the world, as many ashalf of patients are food insecure and that’s a challenge OSF HealthCare andcommunity partners will have to tackle collectively. She also says a communitycare network will need expanded digital tools to allow two-way communication inwhich community partners can also refer individuals to OSF for medical careand, with patients’ permission, allow information-sharing among agencies for acoordinated approach to “whole person care.”