Workflows, Protocols, and the Care Team to Support Screening & Referrals Copy Link

Getting Started

Screening for health-related social needs, making referrals, and conducting warm hand-offs to social services organizations in the community requires a team-based approach.

For a health center that is new to screening for social needs, the following tips can help the planning team get started:

1. Learn about the social services organizations in the community that currently serve the health center’s patient population; leverage the expertise of community health workers and other peer support care team members for this exploration.
2. Engage multiple stakeholders, including social service organizations, early in the planning process.
3. Assess the current processes and workflows for other screenings (e.g., depression screening, pediatric developmental screening). When possible and practical, align screening for social needs with other screening workflows.

Care Team Considerations

The care team member that screens a patient for social needs may be different than the care team member that responds to the patient’s needs. However, it’s important that protocols are in place to ensure that patients’ unmet social needs (positive screens) are responded to in a timely manner.

Various care team members may play a role in identifying patients’ social needs:

• A receptionist at the front desk may administer a social need screening questionnaire on paper or a tablet for a patient to complete on their own while they are waiting for their appointment.
• A medical assistant may conduct a verbal social needs screening while they are rooming a patient.
• A Community Health Worker may conduct patient outreach and administer a phone-based social needs screening.
• A provider may make a warm handoff to a CHW during a patient’s visit to complete a social needs screening.
• Family partners, care coordinators, and peer support members may play a role in identifying and responding to patients’ health-related social needs.

When identifying a workflow for social needs screening, it’s important to understand the needs of the community and patient population. For example, a health center that serves a large population of patients experiencing homelessness may find it beneficial to include a housing specialist (or a CHW with particular expertise on navigating housing issues) on the care team. Health centers will need to determine how much internal expertise and case management they wish to provide, and determine when they will refer patients to outside community-based SSOs.

Training

Ongoing training for community health workers and other care team members who support patients in this work is incredibly important. Trainings should cover tools and techniques CHWs can use to successfully engage members in conversations about the social circumstances and also build their knowledge base of community resources and strategies to address unmet social needs.

Examples of trainings include:

• How to gain trust with patients and engage in conversation about health-related social needs using motivational interviewing techniques   
• How to use trauma-informed approaches to reduce harm, stigma, and judgement
• How to find resources, including trainings on various public benefit programs and community programs

Strategic Partnerships and Investments in the Community Copy Link

A health center can take various approaches to responding to patients’ health-related social needs:

• Referral: Refer a patient to a social service organization by providing the patient with a phone number to call or an address to visit. While this may be the simplest approach, it is often not a successful strategy for ensuring that patient’s ultimately access the service
• Closed-loop referral: track the referral and follow up with the patient to ensure their need has been met
• Warm Handoff: While the patient is present, connect the patient with the SSO and ensure the SSO has the information they need to support the patient

Building trusting partnerships with community-based social service organizations (SSOs) and engaging those partners in the design and implementation of a health center’s screening and referral process is key. Community-based SSOs have the expertise in responding to patients’ social needs; however, the need for support is often much greater than the resources that are available at these organizations. This can often, unfortunately, result in referrals to an organization that does not have the capacity to take on additional clients. That’s why it’s important to engage these organizations early in planning efforts. Understanding their program requirements and intake processes will help make referrals more successful.

When possible, health center leaders should consider leveraging grants or other funding opportunities to expand capacity at SSOs. Other opportunities to expand capacity at SSOs include supporting opportunities for improved data sharing between health centers and SSOs and convening multiple SSO partners to discuss promising opportunities and strategies for effective partnerships.

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  Levels of HRSN & SDH Integration Framework

  Source: Health Begins

  A six level framework to help healthcare and social service partners address health-related social needs. The first level begins with coordination and moves through increasing levels of collaboration and integration.

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  Building Strong Community Partnerships to Address Social Needs

  Source: CMS

  This case study from the Accountable Health Communities Model highlights strategies for engaging community advisors to facilitate cross sector collaborations

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Technology and Tools that Meet the Needs of All Partners Copy Link

Screening Tools

There are numerous screening tools that can be used to assess health-related social needs at the patient level. Choosing a reliable tool and using it consistently ensures that you accurately track and monitor this important information.

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  State of Science on Social Screening in Healthcare Settings

  Source: SIREN (Social Interventions Research & Evaluation Network, UCSF)

  The goal of this report is to synthesize and disseminate recent research on social screening.

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  PRAPARE Screening Tool

  Source: https://prapare.org/the-prapare-screening-tool/

  Protocol for Responding to & Assessing Patients’ Assets, Risks & Experience (PRAPARE) is a national standardized patient risk assessment protocol designed to engage patients in assessing & addressing social drivers of health (SDOH).

  Visit website
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  Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool

  Source: National Academy of Medicine

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  The Hunger Vital Sign

  Source: Children’s HealthWatch

  The Hunger Vital Sign is a validated 2-question food insecurity screening tool based on the U.S. Household Food Security Survey Module to identify households at risk of food insecurity.

  Visit website

Referral Platforms

Many health centers may currently maintain a list of community resources with phone numbers and other contact information. It can be time consuming to maintain these lists and keep the content up to date. There are numerous platforms and tools that can provide support by maintaining resource databases.

In addition, some platforms and tools provide mechanisms for making and monitoring referrals. It’s important to accurately monitor and track this data for many reasons:

1. Understanding the breadth of needs at your health center can help determine where to focus your efforts and recourses
2. Data on referrals can be useful for your partner SSOs. it can help them understand the demand for their services and help them advocate for more funding and resources
3. Sharing HRSN data between health centers and SSOs helps partners to investigate the drivers of HRSNs and direct resources towards addressing those upstream challenges

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  Adopting a Community Resource and Referral Platform: Considerations for Texas Medicaid Stakeholders

  Source: Center for Health Care Strategies

  This brief shares experiences from Medicaid stakeholders in Texas on using community resource and referral platforms to identify and address non-medical drivers of health. While geared to a Texas audience, lessons herein can inform activities in other states to better address non-medical needs of Medicaid populations.

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  Cross-Sector Data Sharing to Address Health-Related Social Needs: Lessons Learned from the Accountable Health Communities Model

  Source: CMS

  This report discusses the importance of effective data sharing between clinical and community partners and shares lessons learned from the Accountable Health Communities Model.

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