ORIGINAL RESEARCH
Rose Gunn, MA; Maura Pisciotta, MS; Molly Volk, MHS, PCMH CCE; Megan Bowen, NCQA PCMH CCE; Rachel Gold, PhD, MPH; Ned Mossman, MPH
Corresponding Author: Rose Gunn, MA; OCHIN, Inc.
Email: gunnr@ochin.org
DOI: 10.3122/jabfm.2023.230047R1
Keywords: Community Resources, Health Information Technology, Loneliness, Referral and Consultation, Social Determinants of Health, Social Risk Factors
Dates: Submitted: 02-11-2023; Revised: 04-28-2023; Accepted: 05-08-2023
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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 four community health centers. Semi-structured 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.