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population may be at risk and narrow the focus of who is likely to benefit from screening for needs in the social domains. Much like the PHQ-2 or PHQ-9 for depression screening, a brief set of questions can lead to further questions to determine which social needs exist. There are also data analytics that can be done by third-party vendors to help narrow the wider net of screening. This may involve sorting by ZIP code or even block or street level to help narrow the screening to patients with a high probability of social needs (a positive SDOH screening). E-referral vendors do not solve the questions of determining Minnesota patients are starting to which patients or groups of patients to screen. benefit from e-referral vendors.

Once individuals who may be at risk are identified, the next step is employing a validated screening tool. There are several such as the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) which was developed the National Association of Community Health Centers; the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) screening tool developed by the Center for Medicaid and Medicare Services; an internally developed set of patient risk screening questions; or an EMR vendor created set of questions. The e-referral vendors are broadly able to incorporate responses from any of these screening tools.

Some organizations and communities may have identified priority needs 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 SUNFLOWER is creating expectations for services or solutions that may not exist within the community. 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 ongoing missions. If health care doesn’t partner with the community and CBOs to discuss the workflows, expected volumes of referrals and payment mechanisms, the CBOs can quickly become overwhelmed. We also cannot assume CBOs will have the bandwidth and ability to have the needed staff to receive, acknowledge, and send back data to the referring organization without some level of support and training. CBOs frequently operate on limited budgets, braided grant funding, and may have high staff turnover, all of which must be factored into efforts to implement referral workflows and utilize any vendor application. Any effort to implement an e-referral system and clinic to community workflows must engage the community partners at the outset. Their voices and concerns need to be included in the planning, implementation, and ongoing operations stages in the spirit of “nothing for us without us.”

As we recognize and account for additional utilization placed on community service agencies, we also need to contemplate and design workflows that do not create unmanageable burden — a key reason to engage CBOs early. We need to be clear about who we are screening, ensuring we don’t cast the screening net too widely and create unnecessary work on the health care side of the partnership. From an access and equity lens, we know that many high-risk populations are not native English speakers and may need special assistance. Screening

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