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Research ArticleOriginal Research

Implementation of Social Isolation Screening and an Integrated Community Resource Referral Platform

Rose Gunn, Maura Pisciotta, Molly Volk, Megan Bowen, Rachel Gold and Ned Mossman
The Journal of the American Board of Family Medicine October 2023, 36 (5) 803-816; DOI: https://doi.org/10.3122/jabfm.2023.230047R1
Rose Gunn
From the OCHIN, Inc. Portland, OR (RG, MP, MV, MB, RG, NM); Kaiser Permanente Center for Health Research, Kaiser Permanente, Portland, OR (RG).
MA
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Maura Pisciotta
From the OCHIN, Inc. Portland, OR (RG, MP, MV, MB, RG, NM); Kaiser Permanente Center for Health Research, Kaiser Permanente, Portland, OR (RG).
MS
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Molly Volk
From the OCHIN, Inc. Portland, OR (RG, MP, MV, MB, RG, NM); Kaiser Permanente Center for Health Research, Kaiser Permanente, Portland, OR (RG).
MHS, PCMH, CCE
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Megan Bowen
From the OCHIN, Inc. Portland, OR (RG, MP, MV, MB, RG, NM); Kaiser Permanente Center for Health Research, Kaiser Permanente, Portland, OR (RG).
NCQA, PCMH, CCE
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Rachel Gold
From the OCHIN, Inc. Portland, OR (RG, MP, MV, MB, RG, NM); Kaiser Permanente Center for Health Research, Kaiser Permanente, Portland, OR (RG).
PhD, MPH
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Ned Mossman
From the OCHIN, Inc. Portland, OR (RG, MP, MV, MB, RG, NM); Kaiser Permanente Center for Health Research, Kaiser Permanente, Portland, OR (RG).
MPH
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Abstract

Background: Screening and referral programs for social isolation and loneliness in older patients increased during the COVID-19 pandemic in primary care settings to mitigate associated adverse health outcomes. This study explores community health centers’ experiences implementing a social isolation and loneliness screening program involving a community resource referral platform integrated into the electronic health record to support referrals.

Methods: A formative mixed methods evaluation in 4 community health centers. Semistructured interviews, observation of implementation meetings, facilitated group discussions, surveys, and utilization data extracted from the electronic health record and community resource referral platform were collected and analyzed concurrently.

Results: Screening for social isolation and loneliness can heighten health center staff knowledge and prioritization of socially isolated older patients. Participants indicate using an integrated community resource referral platform may only be useful in certain circumstances, particularly for those located outside urban areas. The experiences of these health centers indicate that when implementing interventions to mitigate patients’ social isolation and loneliness, it is necessary to consider other resource directories, needed adjustments to referral and documentation workflows, and potential impacts on patients and care teams.

Conclusion: Screening older patients for social isolation could increase care team awareness of social risk; assistance related referral options should be considered carefully.

  • Community Resources
  • Health Information Technology
  • Loneliness
  • Referral and Consultation
  • Screening
  • Social Determinants of Health
  • Social Risk Factors
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The Journal of the American Board of Family     Medicine: 36 (5)
The Journal of the American Board of Family Medicine
Vol. 36, Issue 5
September-October 2023
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Implementation of Social Isolation Screening and an Integrated Community Resource Referral Platform
Rose Gunn, Maura Pisciotta, Molly Volk, Megan Bowen, Rachel Gold, Ned Mossman
The Journal of the American Board of Family Medicine Oct 2023, 36 (5) 803-816; DOI: 10.3122/jabfm.2023.230047R1

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Implementation of Social Isolation Screening and an Integrated Community Resource Referral Platform
Rose Gunn, Maura Pisciotta, Molly Volk, Megan Bowen, Rachel Gold, Ned Mossman
The Journal of the American Board of Family Medicine Oct 2023, 36 (5) 803-816; DOI: 10.3122/jabfm.2023.230047R1
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Keywords

  • Community Resources
  • Health Information Technology
  • Loneliness
  • Referral and Consultation
  • Screening
  • Social Determinants of Health
  • Social Risk Factors

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