Objective: The benefits of Social Determinants of Health (SDoH) is well documented but several studies highlight the complexity of collecting and standardizing SDoH data in a way that makes it relevant to the standard clinical interaction. The purpose of this study is to examine how leveraging an Electronic Health Record (EHR) system can facilitate SDoH screening and its integration into Primary Care encounters, while also using the data collected to meet the identified needs.
Methods: This is an observational study design. EHR and SDoH screening data from 2020 to 2023 at 3 primary care sites were gathered. The study was implemented in 3 phases to streamline and establish the screening and referral processes.
Results: SDoH screening increased by 95% from 2020 to 2022 with a consequent increase in social work referrals and the allocation of resources to a targeted patient population.
Conclusion: Identifying SDoH unique to a community or population can be strategically used to deliver relevant and timely services to patients. This fosters a multidisciplinary, collaborative and integrated approach to patient care.
Keywords: Community Medicine; Community-Based Participatory Research; Doctor-Patient Relations; Electronic Health Records; Family Medicine; Health Disparities; Needs Assessment; Physician's Practice Patterns; Primary Health Care; Resource Allocation; Social Determinants of Health.
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