Addressing Social Needs in the Clinical Setting: Description of Needs Identified in a Quality Improvement Pilot Across 3 Community Hospital Service Areas

摘要

Describe patient social needs in a large midwestern health care system. Health care systems are increasinglyinterested in addressing social needs in the clinical setting for improved health outcomes and lower costs. Thisretrospective cross-sectional analysis of health records data was a population health pilot project which tested adigital platform to screen and refer patients for social needs across three community hospitals serving Chicago andits South Suburbs. The analysis reports on social needs identified based on the referrals made. Electronic healthrecord data were linked to the referral data to describe patient clinical and demographic characteristics. A total of2909 patients had at least 1 social need identified. The mean age was 49 years–21.7 and 65.7 were women. Only33 of patients had 1 social need identified, indicating that if a social need is identified for patients, they most likelyhave social needs from other categories as well. Patients of color, specifically African American patients, were 14more likely to have at least 3 social need categories identified (95 confidence interval of relative risk: 1.02–1.29).Financial stability was the most commonly reported social need (50.7), followed by food and nutrition (43).Transportation (22) and housing (21) were also commonly reported. This population health initiative revealsthat many patients accessing health care have multiple social needs that can be identified at the point of care, andpatterns of need-based referral vary by patient clinical and demographic characteristics.