Electronic Medical Record–Based Referrals to Community Nutritional Assistance for Food-Insecure Patients

Hager, Kurt; Lofthus, Alexandra De Kesel; Balan, Betty; Cutts, Diana

doi:10.1370/afm.2530

Cited by 15 publications

(32 citation statements)

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“…Over 4,000 referrals occurred between January 2015 and December 2017, and Second Harvest successfully contacted 63% of the referrals and assisted 2,533 households. Staff education, training, and standardized screening were critical to success [21]. Health care systems can also refer to local agencies or community-based organizations (CBOs) that can enroll patients in evidencebased federal programs such as Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC) programs.…”

Section: Example #2 -Food Insecuritymentioning

confidence: 99%

Social Determinants of Health 201 for Health Care: Plan, Do, Study, Act

Magnan

2021

NAM Perspectives

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Understanding the social determinants of health (SDoH), social risk factors, and health-related social needs (HRSN) is critical to creating equitable health and care for all patients and communities. Health care systems need to understand their role in enacting relevant strategies, processes, and policies. One way that health care systems can explore what processes and policies work for their patients and their community is using the Plan-Do-Study-Act (PDSA) model. This discussion paper provides frameworks and approaches to using PDSA cycles to implement SDoH, social risk factors, and HRSN efforts, as a follow-up to the 2017 NAM Perspectives discussion paper Social Determinants of Health 101 for Health Care: Five Plus Five [1].

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Section: Example #2 -Food Insecuritymentioning

confidence: 99%

Social Determinants of Health 201 for Health Care: Plan, Do, Study, Act

Magnan

2021

NAM Perspectives

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“…Yet, primary care practices likely still face significant challenges providing social needs referrals due to workflow changes, staffing needed, and technology to support implementation. 14 …”

Section: Introductionmentioning

confidence: 99%

“More than just giving them a piece of paper”: Interviews with Primary Care on Social Needs Referrals to Community-Based Organizations

et al. 2022

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Background Primary care practices are responding to calls to incorporate patients’ social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients’ social conditions, yet little is known about the referral process. Objective To characterize referrals to community-based organizations by primary care practices. Design Qualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization. Participants Administrators at 50 diverse US healthcare organizations with efforts to address patients’ social risks. Main Measures Approaches used in primary care to implement social needs referral to community-based organizations. Results Interviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market. Conclusion and Relevance Referrals to community-based organizations were used in primary care to improve patients’ social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients.

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“…Studies suggest that the use of resource referral systems and screening interventions may increase the number of referrals to community resources, at least in the short term. 18 , 19 Referral platforms may also provide information about broader structural issues that are not confined to the individual, but rather those that unfold within defined communities. For example, information about what resources are most needed in a community can be determined based on search frequency which can then inform resource allocation to those specific needs.…”

Section: Introductionmentioning

confidence: 99%

Calling Your Aunt Bertha for Social Assets: Family Medicine and Social Determinants of Health

DeVetter

Westfall

Carrozza

et al. 2022

J Prim Care Community Health

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Purpose: The sociopolitical determinants of health drive health outcomes and inequities in the United States. Primary care practices are, increasingly, expected by payers and policy makers to assess patients’ social needs. Resource referral platforms provide physicians with information and referral systems for community resources. One commonly used platform is Aunt Bertha/Find Help (AB/FH). The American Academy of Family Physicians (AAFP) Neighborhood Navigator (NN) tool allows physicians and laypeople to search for resources using AB/FH. We sought to describe what users were searching for and to identify patterns to inform resource allocation. Methods: This was a descriptive study of the AAFP’s NN tool. Searches of NN were analyzed to describe what users were searching for. Results: From 2018 to April 2022 there were 168 135 searches. The most common searches were for food and housing insecurity (22%, 21%) and health care referral (20.6%) with 22% more searches in the winter than the spring. There was a 119% increase in searches between 2018 and 2022, and a 47% increase in searches during the COVID-19 Pandemic. In the “Health” category the top 20 subcategories accounted for over 77% of searches. Conclusions: Family physicians and their patients use NN to search AB/FH for community resources to address adverse social determinants of health (SDOH). As expected, searches increased during the COVID-19 pandemic. This type of analysis may help individual clinicians, practices, and health systems prepare for the most common social needs of their patients. Social resource platforms might serve as a robust measure for primary care practice screening and referral for SDOH.

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Electronic Medical Record–Based Referrals to Community Nutritional Assistance for Food-Insecure Patients

Cited by 15 publications

References 0 publications

Social Determinants of Health 201 for Health Care: Plan, Do, Study, Act

Social Determinants of Health 201 for Health Care: Plan, Do, Study, Act

“More than just giving them a piece of paper”: Interviews with Primary Care on Social Needs Referrals to Community-Based Organizations

Calling Your Aunt Bertha for Social Assets: Family Medicine and Social Determinants of Health

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