Addressing Social Determinants of Health

Medical care accounts for a smaller portion of influence over health (20%) than the greater influence of where people live, work and play (80%). Yet health care screening, referral, and care processes infrequently take these community-based social determinants of health (SDOH) into account.

Based on a Community Health Needs Assessment in Duluth, MN, Essentia Health, St. Luke’s Health, and Generations Health Care Initiatives engaged Stratis Health to create new ways of identifying social needs through screening and designing closed-loop referral processes and workflows to assure those patient needs are met. A vendor selection process was undertaken to find the best fit among a small number of emerging technology solutions for the SDOH screening and referral market. As in many other communities prior to the COVID-19 public health emergency, food insecurity was identified as the top need followed by others that will be screened for (and referrals made) as the scope of the work expands.

Actions

Determined the workflows and functional needs to select an electronic SDOH referral resource vendor, resulting in a vendor chosen in February 2020
Created a broader base of relationships between the health care and nonprofit community-based organization partners to prepare for the implementation of the chosen technology screening and referral solution
Implementing a model and workflows for screening and referrals around food insecurity that can be expanded to other SDOH domains and scaled and spread to other communities served by the collaborative partners

We make lives better by…

Designing a system that bridges health care and community to more holistically meet patient needs and ultimately achieve better health:

Strengthening partnerships between health care organizations and community organizations
Reducing health inequities by connecting disenfranchised patients and community members to the services they need are foundational steps to positive health outcomes
Gathering data that will lead to actionable information to uncover additional services that may be needed or capacity of existing services increased

Contact

Susan Severson
Vice President, Health Information Technology
952-853-8538

Customer

Self-funded pilot project – no external contract

Timeline

2019-present

Testimonials

“Working with Stratis Health has been a great experience. Their expertise and perspective have been so helpful in our collaborative work. Thank you Stratis Health.”
– Mary Rapps, Executive Director of Generations Health Care Initiative

“Stratis Health provides expertise in project management which has helped our group identify goals, develop timelines, identify resources required, and create tools to facilitate collaboration. This has been essential for keeping our project moving forward with all partners engaged.”
– Emily Anderson, Community Health Director, Essentia Health