In healthcare, there are many unknowns. The social needs of our patients shouldn’t be among them.
However, we were not surprised to see that only a quarter of hospitals and 15.6% of physician practices are currently screening patients for all five social determinants of health—transportation needs, interpersonal violence, housing instability, utility needs and food insecurity.
While it may seem easy enough for clinicians to ask these questions, it has only recently become common practice. Hard-wiring a community health mindset remains a work in progress.
As one of 32 participants in the CMS’ Accountable Health Communities pilot program, we are testing how this model can help communities as they address health-related social needs.
Strong community partnerships are critical for the pilot’s success. We partner with other local organizations and health systems, including First Nations Community Healthsource and the University of New Mexico Health Sciences Center, by using the same technology platform, sharing screening data and learning from our successes.
Another key element has been hiring community health workers to complete screenings. They begin by asking whether patients want to be screened. If patients accept, they ask about all five areas and, critically, link patients to resources. If a patient discloses food insecurity as a concern, for example, they can be referred to Presbyterian’s Food Farmacy.
Screening for social needs is critical, but it is not enough to ask about needs; we must also help patients address them.
Dr. Jason Mitchell
Chief medical and clinical transformation officer
Vice president of community health
Presbyterian Healthcare Services