Hospitals, nonprofits tackle social determinants of health with digital network of providers

A year ago, a woman arrived at Griffin Hospital’s emergency room with breathing problems. It wasn’t the first time she had turned up with those troubling symptoms, and physicians at the Derby hospital wondered what kept triggering her asthma.

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Waterbury Hospital

Instead of just treating the problem and sending her away, the doctors arranged a home visit. When health officials set foot in her rental unit, the issue was immediately clear: A shag rug carpet – a virtual magnet for dust mites, mold spores and other allergens – lined the floor, a red flag for someone with her condition. After a call to the landlord, the carpet was swapped out and the woman’s symptoms subsided.

Last spring, a specialist at Griffin noticed a patient struggling to manage his diabetes. Follow-up interviews and an assessment of his home revealed that he regularly consumed fast food, and wasn’t good about keeping up with his medication. Nutritional counseling and a better organizational system for his pills helped him get back on track.

Doctors have long acknowledged that social factors – transportation, housing, access to wholesome food and dietary information, personal safety, and employment – influence people’s health outcomes. But addressing those issues can be complicated.

Some hospitals hand out brochures for food pantries or housing agencies. A few place calls to social service groups on the patients’ behalf. And some have set up appointments to survey people’s living conditions.

But there has been no formal way of tracking what happens after a person leaves the hospital. Most of the time, that leaves patients to navigate the intricate network of community programs by themselves. Without access to certain resources, a person may wind up back in the emergency department over and over again.

Health officials are trying to change that. Late last year, the Connecticut Hospital Association rolled out software that logs patients’ progress in obtaining healthy food, stable housing, employment and other resources upon release. Physicians use it to issue referrals, see when appointments with social service groups are scheduled and track what services the patient receives. Hospitals and a constellation of nonprofits across the state have access to the information.

Two hospitals – Griffin and Waterbury – already have begun using the program to address those factors, known as social determinants of health. In less than two months, dozens of patients have been referred to social service organizations for help.

CHA plans to install the software at all 27 of its acute care hospitals over the next two years.

‘It illuminated a need’
Monica Oris and her colleagues at Griffin recognized early on that the conditions in which people live and work have a significant impact on their health.

Stress, a lack of transportation or housing, environmental hazards, and other factors can lead to chronic issues, causing people to rack up bills for repeat medical visits. Patients sometimes cycle through the emergency department with ailments that could be prevented by outside intervention.

Oris, Griffin’s director of population health, and her peers received a federal grant in 2017 to address social determinants for people on Medicare and Medicaid. When patients in those programs came to the emergency room or primary care offices, they were asked a series of questions, such as: Do you have issues with housing? Are there any problems paying for food, or your mortgage? Do you have enough food by the end of the week?

“There are some sensitive questions and ways of asking these questions that hopefully make it easier for people to open up,” Oris said. “We try to make it as comfortable as possible.”

If a person answered “yes” to some of the queries, physicians would hand over information about food or housing services. They could follow up with patients by phone, but there was no consistent way of keeping tabs.

“You could give them information about meals or caregiver assistance or whatever the need was, and you had to sort of expect that the person was going to be able to navigate the system,” Oris said. “It was very difficult for our caregivers to call other agencies because you need to have a release [form] to share information. So we would just expect that the people we were giving these referrals to would access those services.

“There was no real way to follow up.”

In late November, after screening thousands of Medicaid and Medicare patients, employees at Griffin began using the new computer software to make referrals. Under the new system, approval was already in place to share a patient’s information, and it allowed all agencies to track the person’s progress.

The hospital now screens everyone – regardless of insurance status – on a voluntary basis. Workers are looking to expand the practice beyond the ER and primary care offices to all departments.

The idea to evaluate patients for social needs was first tossed around years ago at CHA. The organization launched a pilot program in 2018 testing the approach at four of its member hospitals.

The trial period underscored the program’s importance.

During a three-month stretch, Bristol Health, one of the participants, screened 276 patients and found that many of them – 63% – had some need.

“The themes we saw most heavily were housing insecurity, transportation, food insecurity, and either unemployment or underemployment,” said Rebecca Colasanto, director of behavioral health at Bristol. “I was rather shocked with the amount of food insecurity. It definitely illuminated a need.”

The screening also signaled that there were other, crucial ways to offer patient support.

“If we’re not looking at the whole person, or how some of their medical diagnoses may be the result of short-term or long-term social determinants, we’re not going to cure them,” Colasanto said. “We’re not even going to repair them.”

The hospital association analyzed findings from the pilot program and searched for technology that could formalize patient referrals. Last year, it partnered with software maker Unite Us to launch the digital network.

The system notifies medical staff if a patient misses an appointment with a social service group.

“It allows folks involved in that person’s care to reach out and say, ‘Why didn’t you go? Do you need another appointment? Are you not able to get there because of your work schedule, or your transportation schedule, whatever it happens to be?” said John Brady, CFO of the hospital association. “It allows this holistic care coordination and care team to intervene, rather than waiting for the next crisis episode.”

Along with Griffin, Waterbury Hospital was among the first to introduce the software on a full-time basis last fall. Employees there had been doing work on social determinants but lacked an efficient method for following up with patients.

“It’s been phone calls, it’s been letters and emails – just trying to get a hold of the community organizations to assist the patients,” said Leslie Swiderski, a supervisor for the Waterbury Health Access Program. “We have not had a tracking system to be able to expeditiously turn those needs around.”

The hospital started screening people in an outpatient diabetes program. Eighty-seven patients agreed to answer questions, and all of them were referred for services that included access to food, transportation and housing.

The addition of the software will allow workers to begin assessing patients at the emergency room and other departments, Swiderski said.

Expanding operations
At least three more hospitals are expected to begin using the computer network by the spring.

Nonprofits that work alongside acute care facilities have reported better connections since the online system was launched.

“What’s been challenging is the feedback loop with health care entities. My staff would spend a significant amount of time making sure we could let the hospital know that a patient had connected with us,” said David Morgan, president of the nonprofit TEAM Inc. in Derby, which helps people access food, housing and other services.

With the digital system, “it happens seamlessly,” he said. “You can immediately see that people are getting services, and it saves a lot of time.”

Hospitals are also working to get more nonprofits on board. Waterbury partners with dozens of regional groups, and Griffin has about 35 organizations in its network.

The most pressing concerns reported so far are food and housing, officials with the hospitals and social service agencies said.

During Griffin’s screening of Medicare and Medicaid patients, roughly 25% of the 6,000 surveyed said they had some type of food insecurity.

“They didn’t have enough food in general, or didn’t have good quality food, or didn’t have enough food at the end of the week,” Oris, the program director, said. “It’s alarming.”

Oris said there was only one food pantry in her referral network. Three more are in the process of joining, and she is hoping additional groups come forward.

The next hospitals to adopt the software will be announced in the coming months.

“Our goal is to help folks achieve their optimal level of health,” said Brady. “Part of that is through the health care our members deliver. And part of that is in making sure those most vulnerable – those that have other needs – are able to get them.”