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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 August 2023, jabfm.2023.230047R1; 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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    Figure 1.

    Participating community health center profiles. Abbreviations: CRRP, Community resource referral platforms; CHC, Community health center.

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    Table 1.

    Participant Engagement and Timeline

    Evaluation Engagement
    Health Center / RolePre-Implementation InterviewPost-Implementation InterviewObservationGroup DiscussionSurvey
    CHC 1Feb 2021Jan-Feb 2022Feb 2021–June 2022March 2022Feb 2021
    Associate Medical Directorx   
    Outreach Coordinatorxxxx
    CEOx
    Nurse Managerx
    CIO / EHR Support Analystxx
    Medical Assistantx
    Patient Navigatorxxx
    Nurse Practitionerx
    Front Office Leadx
    Health Center Managerxx
    CHC 2Feb 2021Dec 2021Feb 2021–June 2022March 2022Nov 2021
    VP of QIx
    Case Manager 1x
    Health Resources Managerxxx
    QI Managerxx
    Case Manager 2x
    Case Manager 3x
    Referral Specialistx
    CHC 3July 2021Dec 2021–Jan 2022Feb 2021–June 2022March 2022Nov 2021
    Community Support Directorxxxx
    Clinical Integration Directorx
    CHW 1xxxxx
    CHW 2xxx
    CHW 3x
    CHW 4x
    CHW 5x
    CHW 6x
    CHW 7x
    CHC 4July-Aug 2021Dec 2021–Jan 2022Feb 2021–June 2022March 2022Nov 2021
    CEO xx x  
    CMO xx x  
    Patient Navigator xx   x
    Site Supervisor xx   
    Medical Assistant 1 xx   
    Medical Assistant 2x
    QI Director  x x 
    Nursing Supervisorx
    • Abbreviations: CHC, Community health center; CEO, Chief executive officer; CIO, Chief information officer; EHR, Electronic health record; CMO, Chief medical officer; QI, Quality improvement; CHW, Community health workers.

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The Journal of the American Board of Family     Medicine: 38 (1)
The Journal of the American Board of Family Medicine
Vol. 38, Issue 1
January-February 2025
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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 Aug 2023, jabfm.2023.230047R1; 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 Aug 2023, jabfm.2023.230047R1; DOI: 10.3122/jabfm.2023.230047R1
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    • Methods
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    • Appendix 1. Clinic Staff Interview Guide
    • Appendix 2. CRRP Survey
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  • A Pilot Comparison of Clinical Data Collection Methods Using Paper, Electronic Health Record Prompt, and a Smartphone Application
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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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