SOCIAL DETERMINANTS OF HEALTH E-referral Solutions

E-referral Solutions

Screening and connecting patients to community services

REID HAASE, MA

The American Journal of Preventive Medicine indicates that 80%90% of a person’s overall health is determined by socioeconomic factors and environmental factors (where we live, learn, work, and play). The balance of 10%-20% is attributed to care provided in hospitals, clinics, and other traditional health care facilities.

For many people, the pandemic and racial injustice have compromised their ability to satisfy the foundational needs in Maslow’s pyramid and, additionally, ensure that medical treatment and access either continues to be available or is made available. The problems are daunting when we look at the needs that have escalated in the social domains as organized by the Department of Health and Human (DHHS). These domains include economic stability; education access and quality; neighborhood and built environment; social and community context; and health care access and quality.

To address these concerns, emerging and actionable solutions are helping create a path toward connection and improvement. Health care does not typically factor in upstream structural social conditions that hinder optimal health, but we can utilize enhanced electronic approaches to connect patients with organizations in our communities to address social needs precipitated by the upstream structure. Technology platforms known as e-referral solutions have been available for years and are gaining traction due to the growing global, national, and local health disparities and health equity challenges.

A handful of established and emerging vendors are automating the complex landscape of assembling a catalog of social resources and constructing automated processes of screening and connecting patients to these resources. The technology needs to be accompanied by designing clinic-to-community workflows, as well as educating staff and clinicians about the importance and impact of the 80% of determinants on patient health.

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Addressing The Process

Creating links in the chain between health care and community can improve multiple factors. We may not know which patients are in need or which supportive social services exist to serve patients in a community. Current processes from screening through referral may be nonexistent or manual and inconsistent (e.g., a recommendation to visit an agency, an address, a phone number, or a person to talk to which are jotted down and handed to the patient on a piece of paper). At best, the current referral processes are complex, relying on social workers, nurses, and sometimes doctors who have varying levels of knowledge about the services that exist in their community (also discounting the need to know about qualifications needed to utilize the services, languages spoken, hours of service, etc.).

Unfortunately, the referring health care professional invariably has no idea whether the patient followed through on the referral or whether services were delivered. These are the links e-referral vendors create on behalf of patients. The ills of the social referral process are analogous to breakdowns in medication adherence where there may be no feedback on whether prescribed medications have been picked up from the pharmacy and taken as prescribed.

Minnesota patients are starting to benefit from e-referral vendors applications that enable new workflows to be incorporated into daily encounters with patients which start with a detailed screening/risk identification step. At a basic level, e-referral solutions enable health care and community-based organizations to identify individuals at risk, screen for social needs in a broad set of social categories, and electronically refer patients and community members directly to community-based organizations (CBOs)/agencies that can provide assistance beyond what the health care system is able to or designed to deliver from a social services perspective. An added key benefit is the automated solutions offer a “closed loop” feedback mechanism that a CBO can populate and indicate how and whether the referral was addressed. This critical piece of information is a starting point for a referring organization to understand and analyze the impact and benefit for their patients based on aggregated or individual referral data.

Using the Tools

The first step is to identify which patients or segments of patient populations are at risk. It is helpful to consider which segments within a defined