Hackensack University Medical Center Team Builds EHR Tool to Identify and Address Social Determinants of Health

Screening tool integrates with community resource network management SaaS platform to connect vulnerable patients with resources

Social Determinants of Health

To leverage the electronic health record (EHR) system to identify and address social determinants of health (SDOH) in vulnerable patients, a Hackensack University Medical Center team custom designed a process to integrate CMMI SDOH screening tool into the Epic EHR and a community resource network management (CRNM) software-as-a-service (SaaS) platform.

This cross-platform integration helped hospital staff systematically identify and address SDOH in Medicare and Medicaid beneficiaries across multiple clinical care settings, and support referral efficiency. Their solution also enabled patients to complete the SDOH screening prior to an appointment in the MyChart patient portal. This paved the way to expand this workflow to all patients seeking care at any hospital in the Hackensack Meridian Health network.

As part of the Accountable Health communities grant from CMMI, all Medicare and Medicaid beneficiaries who screen positive for at least one SDOH received a tailored CRS upon discharge or checkout with contact information for community service providers in or near the beneficiary’s ZIP code that may be able to help resolve each SDOH identified. Epic’s Chart Review tool stores the CRS for future health care providers reference, and following discharge, community health workers reach out to randomized and navigation eligible high-risk patients to assist community resource navigation.

In three years of operation, the SDOH EHR solution helped staff screen 111,486 Medicare and Medicaid beneficiaries, identify 7,878 SDOH, and refer 6,103 high-risk beneficiaries to community resources.

While research shows that social, economic and physical environment factors have an estimated contribution of approximately 55 percent to health outcomes that include measures of mortality and morbidity, SDOH often go undetected and unaddressed. While the tool serves patients’ social needs, the team also built it with the goal of sharing the model to address the need for field examples of custom EMR solutions that fit into the workflows of clinical and administrative professionals.

In March 2022, the Hackensack University Medical Center SDOH EHR development team published a paper in the Perspectives in Health Information Management detailing the design, integration and implementation of their strategy to identify and screen inpatient, outpatient, and emergency department Medicare and Medicaid beneficiaries for SDOH via EHR decisional support clinical workflows integrated with a CRNM SaaS platform. Upon patients’ responses, staff refer beneficiaries with identified social needs to community resources. Development was an interdisciplinary process with input from technical, administrative and clinical experts at all phases.

The project was supported by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services.

Learn more about innovative geriatric care at Hackensack University Medical Center.

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