In 2020, Erie Family Health Centers identified the challenges faced by healthcare providers, nurses, and staff in addressing social determinants of health (SDOH) for their patients. Responding to feedback from both providers and patients, they implemented a two-step process, starting with a simplified prescreening question to gauge patient interest in connecting to resources. This approach, focused on improving patient care outcomes and reducing the burden on healthcare personnel, streamlined the screening process and maximized efficiency.
The results were significant, with 53,323 patients screened from May 2020 to February 2022, showing the initiative’s broad impact. In the initial phase, 74% of patients expressing interest in follow-up were successfully connected to resources. In Phase 2, 79% of those contacted by phone screened positive for needs and received necessary connections. Beyond addressing social needs, the program fostered staff fulfillment by implementing a “no wrong door” policy and training all staff to ask the prescreening question, distributing the responsibility and enhancing the overall impact. The initiative, carried out in collaboration with Alliance Chicago, Erie Family Health Centers, Pillars Community Health, and Infant Welfare Society of Chicago, represents an innovative and successful model for SDOH screening. As of April 2023, the program continues to make a positive impact.