Screening for social determinants of health in transitional care patients and partnering with the faith community to address food insecurity

PURPOSE/OBJECTIVES: The purposes of this project were to collect and document social determinants of health (SDOH) data, and to partner with the faith community to address identified food insecurity. PRIMARY PRACTICE SETTING: The setting for this project was an ambulatory care clinic in Guilford County, North Carolina. The clinic offers care to patients discharged from a regional medical center who have no insurance and/or primary care providers. FINDINGS/CONCLUSIONS: Clinic staff successfully developed and implemented a screening tool for entering SDOH data into the electronic health record (EHR) charts of clinic patients. Results demonstrated that 52% of clinic patients reported food insecurity. The clinic collaborated with the faith community to provide donated food bags to patients in need. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: SDOH data were largely absent from the EHR before the clinic case manager started this project. Results of the screening tool demonstrated higher rates of food insecurity than expected. The case manager worked with the faith community to address immediate needs of food insecurity. The case manager plans to share SDOH information with the wider community to affect positive change and to encourage other clinics and departments to start collecting SDOH data.