AAACN: Automating the Assessment and Addressal of Care Needs - Bridging SDOH Gaps in Ambulatory Care (Spotlight Poster)

According to the National Academy of Medicine’s latest Future of Nursing report (2021), ambulatory care nurses are uniquely positioned to assess and address healthcare inequities and the social determinants of health (SDOH) for our communities. At a large urban academic medical center encompassing over 90 clinics across a multi-city metroplex that hosted over 2.5 million patient encounters in 2023, addressing SDOH was identified as a significant opportunity to impact community health outcomes.
In the summer of 2024, a multidisciplinary workgroup was formed, including nurse executives, nursing professional development practitioners (NPDs), information resource (IR) analysts, and clinical workflow informaticists (CWI). This workgroup aimed to evaluate current SDOH workflows and assess the potential for new workflows, such as automated SDOH screening and resource referrals. Initial analysis revealed limited SDOH documentation, lack of available resources in the electronic health record (EHR), and deficient access to social workers (SW), pointing to a limited addressal of SDOH needs. Concurrently, additional workgroups were tasked with establishing a pool of available SWs to support primary care clinics and improve SW workflows to help address patient care needs. Collaboration with IR analysts and CWI led to an innovative EHR-integrated workflow that included automated patient questionnaires and automated referrals to the social work (SW) team that triggers after high-risk areas are identified.
Three primary care clinics were identified to pilot the automated workflows, which began in November 2024. To prepare staff before the pilot implementation, socialization of the project took place with clinic leadership, followed by live virtual training with nurses, medical office assistants (MOAs), and SWs. This training included the background and purpose of assessing SDOH needs along with visual demonstrations of the workflow. Upon completion of the training, tipsheets with workflows were provided for clinical staff and leadership to ensure all employees were prepared and the workgroup was available for feedback.
Before implementation, only 23 referrals were placed to the newly available SW team over three weeks. Assessment of SDOH was scarce amongst health system clinics before implementation, and the resources available were insufficient for the nurse to adequately provide to patients if a need was identified. By the time of implementation, there were over 3,000 resources identified and created within the EHR for nurses to share with patients. Pilot data will capture anticipated increases in SW team referrals and provide baseline insights for SDOH reassessment post-intervention.
Initial outcomes after one week of pilot implementation include a 42% completion rate of assessments, with 14 of those identifying high-risk needs and producing automated referrals to SW. Additional outcomes to be measured will also include updated completion rates, referral counts, and the secondary impact on reassessed high-risk SDOH needs. Upon completion of the pilot, implementation will be expanded to all primary care clinics in the health system, and outcomes will be tracked through our EHR dashboard. Future implications include expansion to these clinics and the potential that this project could dramatically influence SDOH initiatives and workflows throughout the numerous remaining clinics within the organization.