Program meets social needs of 90% of patients

WASHINGTON – An innovative screening and referral model using electronic health records (EHRs) helped patients overcome social determinants of health (SDOH) by providing them with resources they had requested, according to a study.

“Our goal was to find whether this pilot program is feasible to systematically screen and refer patients for social needs in ambulatory care,” said Pablo Buitron de la Vega, MD, of Boston Medical Center (BMC) at the annual meeting of the Society of General Internal Medicine.

The program, called THRIVE, helps clinicians better understand patients’ social needs through a screening process to improve their health. THRIVE uses EHRs to document patient needs related to SDOH by using ICD-10 codes. This facilitates accurate data reporting and provides insight into social impacts on a patient. This component also matches SDOH needs to referral resources. In this pilot program, patients were screened during their primary care visits.

As of December 2018, THRIVE has demonstrated feasibility across all of its clinics. Eighty-two percent of patients were screened for social needs; 86% of patients received an ICD-10 code to document their social needs in their medical files for diagnosis and billing; and 90% of patients were provided with the resources they requested.

The observational survey screened 50,532 unique patients seeking care at BMC between July 2017 and December 2018. In this population, 70% were underserved minorities (with 60% black patients and 10% Hispanic patients), 50% were below the federal poverty level, and 30% did not speak English as their primary language.

Of the screened population, 28% (13,975) of the patients identified having one or more social need. In addition, 19% (9,714) of patients requested help with one or more of their needs. The most prevalent needs were food insecurity, housing/shelter, and education, with 11% of patients listing each of these as a need.

The pilot program has been scaled up to include all patients presenting to 13 ambulatory clinics in family medicine, obstetrics and gynecology, infectious diseases, and pediatrics at Boston Medical Center.