Building a comprehensive SDOH screening and response model within a health system
This 3-part webinar series will highlight the comprehensive approach taken by The MetroHealth System to identify and address the health-related social needs of patients and the wider community. The series will provide attendees with tactics to launch an integrated process to screen patients for SDOH and connect patients to programs and services that meet their social needs. It will also show the role data analytics plays in program design, evaluation, and research, through the development of an interactive data dashboard and the merging of internal and external datasets.
In 2019, The MetroHealth System in Cleveland, Ohio created the Institute for H.O.P.E.TM to help address the Social Determinants of Health (SDOH) within a vulnerable patient population. The goals of the Institute for H.O.P.E.TM are to improve the health of the population, promote opportunities for change in practice, develop partnerships within the community and empower individuals to live their healthiest lives. Major initiatives of the Institute include SDOH screening for all adult patients, and various initiatives designed to connect patients with resources to meet their health-related social needs, including an e-referral system and a team of Community Health Workers. Data analytics is a critical component of the overall strategy, providing the backbone for risk stratification, development of interventions, and evaluation of impact.
Download this one-pager with key takeaways from the series: Building a comprehensive SDOH screening and response model within a health system (PDF)
Part 1–Screen: Building an Integrated SDOH Screening Process
About 80% of an individual’s health is controlled by conditions that go beyond traditional medical care. Known as the Social Determinants of Health (SODH), these conditions include where you live, what is happening around you, your socioeconomic status and education level, and your access to stable housing, nutritious food, reliable transportation, and job training/opportunities. The first step in addressing SDOH needs is to identify what and how SDOH risks impact the community.
This session will cover how to set up the initial process of an SDOH screener that aligns with your community’s risk factors and addresses the social needs of interest. This will include a detailed explanation on question definitions and how to measure a patient’s risk within each SDOH category. This session will also include best practices for distributing SDOH screens within your community or hospital and what lessons have been learned through MetroHealth’s journey within the screening process.
PANELISTS:
- Nabil Chehade, MD, EVP, Population Health and Corporate Services, MetroHealth
- Kevin Chagin, Manager, Advanced Analytics & Data Operations, Institute for H.O.P.E.TM, MetroHealth
- Mark Kalina Jr., Senior Analyst, Institute for H.O.P.E.TM, MetroHealth
- Andrea Orosz, Systems Analyst II, Information Services, MetroHealth
- Jordan Adkins, Clinical Informatics Analyst II, Clinical Informatics, MetroHealth
Part 2–Connect: Building bridges from health care to social care
As health systems seek to address their patients’ health-related social needs as a component of overall care, it is critical to recognize the value of effective processes, programs, and partnerships. This session will highlight the multiple ways The MetroHealth System is responding to social determinants of health (SDOH) screening results as part of its comprehensive strategy to identify and address the health-related social needs of its patients.
The session will discuss the electronic referral platform’s use and role in connecting patients with community-based services, how Community Health Workers assist patients with identified health-related social needs, and the process of developing programs to meet specific needs. In addition, panelists will address how data analytics is essential to all these efforts. A representative from a community-based organization will also share their perspective on unique ways to work with health systems to meet mutual goals.
PANELISTS:
- Kevin Chagin, Manager, Advanced Analytics & Data Operations, Institute for H.O.P.E.TM, MetroHealth
- Karen Cook, Director, Healthy Families & Thriving Communities, Institute for H.O.P.E.TM, MetroHealth
- Sarah Woernley, Nurse Manager, Institute for H.O.P.E.TM, MetroHealth
- Alissa Glenn, Director of Community Health and Nutrition, Greater Cleveland Food Bank
Part 3–Assess: Building a Data Process for Reporting, Research and More
Measuring the impact of Social Determinants of Health (SDOH) screening and connecting people with resources to address their social needs is critical for evaluating programs, identifying gaps in health equity, and driving policy change. Specifically, how does a health system use data to help improve the screening and referral process, develop or improve new programs, and conduct meaningful research? The MetroHealth System has developed a system that combines SDOH screening results with internal and external data, which allows for a comprehensive understanding of SDOH’s impact and utilization in the hospital system. A dashboard was also developed to help identify critical insights, allowing users to interact with the SDOH screening and referral data.
dataset of multiple sources of information, a process that will help providers understand how SDOH impacts the community. Session participants will also learn how to set up their dashboard and a series of high levels reports, information that is essential in telling a SDOH community impact story. The session will also explore using data in process improvements, evaluating and developing new targeted programs, and creating quality research.
PANELISTS:
- Kevin Chagin, Manager, Advanced Analytics & Data Operations, Institute for H.O.P.E.TM, MetroHealth
- Ashwini Sehgal, Physician, Director of Research and Evaluation, Institute for H.O.P.E.TM, MetroHealth
- Mark Kalina Jr., Senior Analyst, Institute for H.O.P.E.TM, MetroHealth
- Jin Kim-Mozeleski, PhD, Assistant Professor, Department of Population and Quantitative Health Sciences and Core Faculty, Prevention Research Center for Healthy Neighborhoods, Case Western Reserve University