Conference Coverage

Pilot program addresses social determinants of health



A new pilot program addresses the social determinants of health in clinical practice through screening and referring patients with unmet social needs to the right resources.

Jane Lindahl, Hofstra University, Hempstead, NY Jennifer Reising/MDedge News

Jane Lindahl

The program, called SHAPE (Social Health Alliance to Promote Equity), was designed to screen patients across multiple social categories. In-house patient navigators, some bilingual, were trained on how to work with diverse populations and were able to address unmet patient needs through referrals to individualized resources. Physicians could refer patients to the following local community partners:

The legal partners provided free assistance to patience with legal needs.

“By implementing a program where you address the nonmedical social needs, you will actually improve the overall health of the patient. You can’t just address the biomedical needs of your patients, you need to understand their home environment, their background, and social situations they’re going through to keep them healthy,” said Jane Lindahl at the annual meeting of the Society of General Internal Medicine. Ms. Lindahl is a research assistant at Cohen Children’s Medical Center at Northwell Health in New York.

The SHAPE program was conducted at two internal medicine and pediatric primary care clinics at Northwell Health, a large academic hospital system in New York. It was originally created in the pediatric practice in August 2016 and expanded to the internal medicine practice in June 2018. A medicolegal partnership was created as part of the program in October 2018.

The patient population comprised low-income, racially ethnic, primarily Medicaid and uninsured individuals, including a high number of documented and undocumented immigrants. While 927 patients were screened, 590 screened positive for social determinants of health (SDOH). Of those 590 patients, 190 patients connected with patient navigators for intake and accepted initial assistance and 74 patients were connected to resources.

Screening was based on patients’ completion of a one-page SDOH form in the waiting room of their physician’s office on the same day of their annual visit. There were 15 categories of social needs identified on the screen.

After the screening, the results were discussed with the patients and the necessary referrals were determined. The screening indicated that the largest needs for the patients were health/dental insurance (cited by 296 people), education (cited by 269 people), and health literacy (cited by 225 patients).

Those who had emergent social needs were referred to on-site social workers and providers to address such needs. The emergent social needs included being a victim of domestic violence, being homeless, having an imminent eviction, and having imminent deportation.

Those patients with nonemergent social needs received referral and follow-up processes within 48 hours.

After a referral was made, the patient navigator followed up every 2 weeks with the patient to check on the status of the referral and social needs. After this period, a final phone interview was conducted to get feedback on the patient’s experience and SDOH status.

Ms. Lindahl had no financial conflicts of interest to disclose. The program was funded by Robert Wood Johnson Foundation Clinical Scholars Grant, Health Leads, Collaborative to Advance Social Health Integration, N.Y. State Delivery System Reform Incentive Program, and United Hospital Foundation.

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