ongoing missions. If health care doesn’t partner with the community and population may be at risk and narrow the focus of who is likely to benefit from CBOs to discuss the workflows, expected volumes of referrals and payment screening for needs in the social domains. Much like the PHQ-2 or PHQ-9 mechanisms, the CBOs can quickly become overwhelmed. We also cannot for depression screening, a brief set of questions can lead to further questions assume CBOs will have the bandwidth and ability to have the needed staff to determine which social needs exist. There are also data analytics that can to receive, acknowledge, and send back data to be done by third-party vendors to help narrow the the referring organization without some level of wider net of screening. This may involve sorting by support and training. CBOs frequently operate ZIP code or even block or street level to help narrow on limited budgets, braided grant funding, and the screening to patients with a high probability of may have high staff turnover, all of which must social needs (a positive SDOH screening). E-referral be factored into efforts to implement referral vendors do not solve the questions of determining Minnesota patients are starting to workflows and utilize any vendor application. which patients or groups of patients to screen. benefit from e-referral vendors. Any effort to implement an e-referral system and Once individuals who may be at risk are clinic to community workflows must engage the identified, the next step is employing a validated community partners at the outset. Their voices screening tool. There are several such as the and concerns need to be included in the planning, Protocol for Responding to and Assessing Patients’ implementation, and ongoing operations stages in Assets, Risks, and Experiences (PRAPARE) which the spirit of “nothing for us without us.” was developed the National Association of Community Health Centers; the As we recognize and account for additional utilization placed on community Accountable Health Communities (AHC) Health-Related Social Needs service agencies, we also need to contemplate and design workflows that do not (HRSN) screening tool developed by the Center for Medicaid and Medicare create unmanageable burden — a key reason to engage CBOs early. We need to Services; an internally developed set of patient risk screening questions; or be clear about who we are screening, ensuring we don’t cast the screening net too an EMR vendor created set of questions. The e-referral vendors are broadly widely and create unnecessary work on the health care side of the partnership. able to incorporate responses from any of these screening tools. From an access and equity lens, we know that many high-risk populations Some organizations and communities may have identified priority needs are not native English speakers and may need special assistance. Screening through a community health needs assessment (CHNA) or aggregated data from individual screening results, but are challenged by not having CBOs/ E-referral Solutions to page 344 agencies that provide corresponding services for each social domain in the screening. Broad patient population screening has the benefit of collecting data that can be used to better support structural needs changes and can be used for policy work at many levels. An adverse effect that must be considered when deciding on the breadth of questions and whom to screen is creating expectations for services or solutions that may not exist within the community.
SUNFLOWER SPREAD
Taking Action Steps Once the screening steps have been completed, referring is where the strength of the e-referral solutions lies. All e-referral vendors rely on a database of local CBOs they build (using different data aggregation and community outreach techniques) that is maintained on a regular basis and serves as a “phone book.” This enables immediate matching from the needs-based screening to the appropriate services, whether based on location, hours, languages spoken, or other dimensions. The “needs to services” matching algorithm is typically highly customizable and eliminates the uncertainty of which services are appropriate for a patient, while eliminating the need to rely on roles or individuals within an organization. An electronic social needs referral is indeed akin to a prescription. It is simply a social services prescription that can direct patients to the most appropriate services based on list of parameters that each vendor makes available. The agencies that receive these referrals (and are participating in the vendor’s network of CBOs) can close the loop and send confirmation back to the referring source (whether health care or another source such as another CBOs, school, etc.). Receiving this information helps determine how effective the workflow has been and whether the services available are meeting the social needs identified. It is important to keep in mind that even in the best of times, many CBOs are constrained in their ability to deliver services and support their
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MINNESOTA PHYSICIAN MARCH 2021
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