System approaches to social determinants of health screening and intervention

Social determinants of health (SDOH) impact life expectancy and morbidity. More than just poverty, social inequality associated with race, ethnicity, language, gender identity, or education leads to differential health outcomes. Not all SDOH are modifiable but some social needs — such as food insecurity, transportation, or housing — can be addressed with the hope of impacting long-term health outcomes. But systems, processes, and people to tackle social needs exist haphazardly across health care systems and communities. Widespread and durable availability of the resources and workflow models to favorably modify SDOH is uncommon in outpatient practices. Therefore, UNC Health Care System aimed to increase screening and action on SDOH across its large organization in North Carolina. UNC Health aimed to increase screening both to inform patient care and to understand population level needs. Using existing infrastructure and governance, new workflows, and modifying responsibilities for existing population health employees, UNC Health developed and spread new processes for collecting and acting on social needs (food insecurity, financial resource strain, housing instability, and lack of reliable transportation). In the first year, the health system screened almost a quarter of a million patients for at least one social need in its primary care network. Sixteen hundred referrals have been placed to a new community health team to assist patients in meeting their social needs. An internal website with community resources that may facilitate such referrals has been accessed almost 3,000 times by more than 1,600 unique users in the same time period. Providers, practices, patients, and health care systems benefit from standard workflows and centralized resources to address social needs. UNC Health continues to follow long-term data to determine if addressing social needs may ultimately help reduce health care disparities.