Addressing health-related social needs through systematic screening and integration of a social care technology platform

Duke Health has found that it is easier to refer patients to resources that address food insecurity and other social needs if every clinician has access to that referral process through the electronic health record. Duke Health successfully implemented systematic screening for health-related social needs (HRSNs) and NCCARE360, a social care referral network and technology platform, within its electronic health record (EHR). Using a tandem strategy of discrete HRSN identification (screening) and then referral placement, Duke Health increased overall identification of patient HRSNs and the ability to track outcomes of referrals. Using flexible point-of-care screening workflows led to effective and sustained HRSN screening, averaging 8,500 patients per month across 32 ambulatory clinics and inpatient encounters over 18 months. Duke Health negotiated an enterprise-wide license of NCCARE360 to permit all EHR users to place and view referrals to community and government resources rather than limiting the referral function to its social workers. Distributing the work across clinical roles and leveraging the EHR integration to screen and refer, Duke Health attained a tenfold higher referral rate than peer North Carolina institutions that were also using NCCARE360. Clinical locations with dedicated support staff, such as a population health nurse trained in social resource allocation, were more successful in placing initial referrals. Duke Health recognized a need for a human connector to facilitate follow-up for service navigation and verification of referral completion.