Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico

Abstract

Although it is known that the social determinants of health have a larger influence on health outcomes than health care, there currently is no structured way for primary care providers to identify and address nonmedical social needs experienced by patients seen in a clinic setting. We developed and piloted WellRx, an 11-question instrument used to screen 3048 patients for social determinants in 3 family medicine clinics over a 90-day period. Results showed that 46% of patients screened positive for at least 1 area of social need, and 63% of those had multiple needs. Most of these needs were previously unknown to the clinicians. Medical assistants and community health workers then offered to connect patients with appropriate services and resources to address the identified needs. The WellRx pilot demonstrated that it is feasible for a clinic to implement such an assessment system, that the assessment can reveal important information, and that having information about patients' social needs improves provider ease of practice. Demonstrated feasibility and favorable outcomes led to institutionalization of the WellRx process at a university teaching hospital and influenced the state department of health to require managed care organizations to have community health workers available to care for Medicaid patients.

Social Determinants of Health and Primary Care: Intentionality Is Key to the Data We Collect and the Interventions We Pursue

“…They found that administering the survey did not significantly lengthen the visit itself, but the results were not stored in the EHR for future reference or action. Similarly, Page-Reeves and her team 10 at the University of New Mexico created an 11-question instrument they used to screen 3000 patients at 3 different family medicine clinics. The WellRx pilot, spanning housing, income, food insecurity, substance abuse, transportation, and employment, among other domains, showed that 46% of screened individuals had 1 social need, whereas 63% faced multiple needs.…”

Agriculture and Health Sectors Collaborate in Addressing Population Health

“…7,8 Most who work in the health sector, however, are unaware of the benefit to population health represented by each state's Cooperative Extension Service, a resource with a lengthy history of addressing communities' health, social, and economic needs. For example, the Cooperative Extension Service advances rural development by helping growers increase crop yields; improves quality of life for individuals, families, and communities through its Family and Consumer Sciences programs (formerly "home economics"); and fosters youth development and educational success through its 4-H youth programs.…”

“…[1][2][3][4] Some approaches to addressing this need include broadening the training and scope of work of health professionals, 5,6 and expanding the health care team to include community health workers who offer skills in working with the cultural, ethnic, or geographic populations from which they come. 7,8 Most who work in the health sector, however, are unaware of the benefit to population health represented by each state's Cooperative Extension Service, a resource with a lengthy history of addressing communities' health, social, and economic needs. For example, the Cooperative Extension Service advances rural development by helping growers increase crop yields; improves quality of life for individuals, families, and communities through its Family and Consumer Sciences programs (formerly "home economics"); and fosters youth development and educational success through its 4-H youth programs.…”

Advancing Social Prescribing with Implementation Science

“…First, although findings from some evaluations of SDHrelated interventions suggest that specific programs can decrease social needs and improve health [21][22][23][24] , relatively little research addresses the impacts of social prescribing initiatives on patient and provider experience of care, health outcomes, health care costs, and utilization. 25 Ideally, gaps in effectiveness research will be filled through federal demonstration project evaluations, including evaluations of Health Homes 19 , CPCϩ, and the newly launched Accountable Health Communities Program 14 , to the extent that social prescribing com-ponents can be distinguished from other care model components.…”