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

CHC 1 Case Study

Located more than an hour’s drive from the nearest city, CHC 1 is in a rural town of roughly 500 people, of whom the majority are more than 65 years old. The CHC has provided affordable health care to the community since the 1970s and the staff have long-established relationships with their patients. Their leaders were interested in participating in this pilot effort because of their largely older – and potentially isolated – patient population. This clinic had several years of prior experience screening for social risks and providing community referrals involving a CRRP other than findhelp and lacked EHR integration.

Clinic staff started screening for SI/L and using the CRRP within 2 months of the initial training provided for the pilot study. Their workflow typically started with a article-based screening questionnaire handed to patients by front desk staff or a medical assistant. Because this health center already had substantial experience and an established workflow screening for social risks in adult patients, they incorporated the SI/L questions into their existing approach. For patients indicating social isolation, a transfer of care was made from the care team member initiating screening to a patient navigator tasked with identifying an appropriate CBO. Referrals for CBOs were typically provided directly from the patient navigator to the patient, either via phone call or mailed letter. The patient navigator documented referral information in the EHR and subsequently updated the chart with the referral ‘outcome’ (ie, whether the patient received the services to which they were referred), if they had time to ask the CBO or patient about their referral. During the study period (January 2021–June 2022), CHC 1 administered 1754 SI/L screening questionnaires to patients aged 50 and older. Of those, 694 indicated experiencing SI/L. Seventeen referrals were placed through the EHR-integrated CRRP, indicating their preference for making referrals through different means, as described below.

Seeking to engage as many patients as possible early in the pilot, CHC 1 developed a bilingual postcard with information about SI/L and a QR code that linked to the free CRRP website, which patients could use to look up CBOs. The clinic faced significant staffing shortages during the pilot period, requiring periodic closures. Clinic staff also found using the CRRP to be challenging due to 2 related issues: 1) there was limited availability of CBOs in their region, and 2) of those available, none were listed in the CRRP. The lack of known CBOs in the CRRP could be due to a breakdown in any of the steps to add a CBO outlined above (ie, CRRP staff exploration, clinic resource request, CBO validation process). Despite the clinic manager’s efforts to encourage their local CBOs to add their information to the CRRP, no new CBOs materialized in the database, which restricted the CHC’s ability to place referrals using the CRRP. Participants reported that the perceived impact on care was limited. The clinic manager shared,

We just need the resources to be there so [the CRRP] is worth using. Because right now we’re kind of separated into multiple workflows because we don’t have all the resources in [CRRP]. We’re like, “well if you can’t find it here then you need to start here and go here.” If we had everything in one location, then we could have one solid workflow for it.

As a result of these barriers, CHC 1 opted to continue screening for SI/L but discontinue their use of the EHR-integrated CRRP after the pilot period ended. They chose to use the free unintegrated, web-based version of the CRRP, but only in instances where it was useful a (eg, for a patient asking for resources in neighboring zip codes). CHC 1 now primarily relies on their clinic staff’s local knowledge of available resources and internally maintained list of resources to refer patients, which was the system they relied on before CRRP integration.

CHC 2 Case Study

CHC 2 serves patients in 2 counties in a geographically isolated area. Founded in the early 1970s to provide health care access to surrounding rural logging communities, CHC 2 had strong leadership support for this effort. Implementation of SI/L screening and integrated CRRP began 7 months after the pilot start date. Activities focused primarily on designing, building, and implementing a social risk screening program, and an intern was engaged to add and/or update CBO listings in the CRRP. Because social needs screening was new to this organization, they kept their screening and referral workflow small in scope by limiting it to a single care team member. The case manager screened for SI/L in case management office visits for all patients aged 50 years and older, then utilized the CRRP or their own local knowledge to refer patients to community resources. Both resource referrals were provided to patients by way of verbal or written CBO information, with the referral information being documented by the case manager in the patient’s record. The case manager then systematically called patients or CBOs to confirm that the patient received the services to which they were referred and documented this in the EHR. During the study period CHC 2 administered 84 SI/L screening questionnaires to patients 50 and older. Of those, 69 indicated experiencing SI/L. Thirty-six referrals were placed through the EHR-integrated CRRP but is not comprehensive of the different ways they made referrals, described below.

CHC 2 participants perceived the integration of the CCRP in the EHR to impact patient care favorably by creating efficiencies, yet they experienced challenges related to competing demands, staff turnover, and the considerable effort to populate the CRRP with CBOs. One leader reflected on the work their intern did to populate the regional offerings in the CRRP,

As lovely as the platform sounded at the very beginning, until we had a person that could do this work, it was a real point of discussion if we should participate. It took [the intern] a lot of time to call these organizations. A lot of CBOs have one or two people that work at them, so they don’t have time themselves to call him back and flesh out all the questions that he has and upload and verify their information in [the CRRP].

Due to these barriers and the burden placed on the Case Manager, CHC 2 delayed a larger clinic-wide rollout of their new screening and referral workflows and chose not to use the EHR-integrated CRRP after the pilot period ended but continued to screen for SI/L and provide referrals mostly based on local staff CBO knowledge.

CHC 3 Case Study

CHC 3 has a catchment area covering a patient population on >20,000 square miles, with small towns dispersed throughout. Started by volunteers to provide health care access to underserved communities, CHC 3 had strong leadership support in raising clinic staff awareness of social isolation risks among older community members. This CHC implemented SI/L screening and referral workflows approximately 3 months after their initial training, which was conducted by 1 care team member, a community health worker (CHW). As they had only just started a social risk screening program, their implementation approach was smaller in scope. In most cases, referrals were made by the CHW copying CBO information from the CRRP and pasting it into a document which was printed and shared with patients. Referral information was documented in the patient chart, and the CHW followed up with the referred patient or CBOs about referral outcomes, as time allowed. During the study period CHC 3 administered 243 SI/L screening questionnaires to patients 50 and older. Of those, 118 indicated experiencing SI/L. Thirty-four referrals were placed through the EHR-integrated CRRP.

CHC 3 faced barriers related to limited CBOs in their rural community, and of those CBOs, contact information was either outdated or missing entirely from the CRRP. Of CBOs listed in the CRRP, many did not accept referrals through the CRRP, which rendered the CRRP less useful. A CHW at this CHC commented,

I am finding not all [CBOs in the CRRP] accept referrals from other organizations. I don’t know … who makes those decisions to say yes, we accept referrals, and these are the workflows we need set up in order to accept referrals … And so I guess when I participated in this pilot, I didn’t think that even if they’re searchable, doesn’t mean they’re going to accept referrals.

Throughout the pilot period, this CHC continued to conduct SI/L screening. Participants shared that the most noticeable impacts on patient care were that it saved time when patients needed referrals outside the CHC’s region. However, due to the drawbacks with the CRRP described above, they often used other resources such as a clinic-developed directory or staff knowledge to identify CBOs. They discontinued use of the integrated CRRP at the end of the pilot period but planned to continue to screen for social risks and use the free web-based version of the CRRP to search for CBOs outside of their region for patients requesting it. For patients requesting referrals locally, CHC 3 transitioned back to using staffs’ local knowledge and their health center-maintained CBO directory.

CHC 4 Case Study

CHC 4 is located in a predominantly agricultural community close to a large metropolitan area. This CHC system was created in the 1970s to provide health care access for the community’s agricultural workers, and it continues to serve these workers and others in the region. This CHC had prior experience screening patients for social risks and referring them to CBOs via a nonintegrated, regionally focused CRRP. CHC 4 participated in the pilot because their CRRP platform was being phased out, and they were motivated to try a CRRP that could interface directly with the EHR. Implementation began 7 months after the pilot started in all clinics in their health system. This health center had experience screening for social risks and decided to add the SI/L questions to their existing screening instrument and workflow. CHC leadership also arranged staff trainings in motivational interviewing techniques for those involved in screening and providing referrals to patients for SI/L. During the study period CHC 4 administered 2565 SI/L screening questionnaires to patients 50 and older. Of those, 82 indicated experiencing SI/L, all of whom received referrals placed through the EHR-integrated CRRP.

Medical assistants provided the SI/L questionnaire to the patients during rooming at an office visit, reviewed the results with the patient, and offered to connect them with a navigator for additional support. If desired, the navigator met with the patient during the visit and provided referrals to CBOs by way of printed CBO information from the CRRP and sometimes via text, if requested by the patient; alternately the navigator would call the patient if they were unable to see them during their office visit to share referral information verbally or via text message. Referrals were sparsely made directly through the integrated CRRP, more often going to patients directly for them to contact the CBO. The Navigator documented referrals in the patient chart but would generally not conduct follow-up related to the referral. The CHC appreciated the focus of SI/L during the COVID-19 pandemic. A member of leadership shared,

If there’s a silver lining to the pandemic, it’s made it socially acceptable to be lonely … For our seniors that have been isolated by the pandemic, they’re all universally feeling the loneliness of the pandemic, so somebody asking about that … There’s not as much stigma anymore. So, saying that there’s something that we can do about it and that we can help connect you to others is sort of a relief for some people.

CHC 4 faced fewer challenges in searching for CBOs in the CRRP, in contrast to the other pilot locations, due to their location near an urban center with access to more CBOs, and more populated CRRP. Participants perceived that use of the CRRP impacted the care they provided by streamlining referrals and ensuring that patients could quickly access needed information. They were the only pilot clinic that chose to continue screening for SI/L and also continue to use the integrated CRRP beyond the pilot period, and when it ended, they began looking into building reporting and interoperability functionality to their CRRP.