YNHH to launch project to assess, assist patients with social needs

Medical records and examinations yield critical information about a patient, but there are other factors that can significantly affect a person’s health.

Does the patient have stable, safe housing? Enough food? Reliable transportation? Over the years, Yale New Haven Hospital has become increasingly involved in identifying and improving these and other factors, called “social determinants.”

This summer, the hospital will launch an Accountable Health Communities (AHC) program to screen certain patients for social determinants and connect them with services to meet their health-related social needs. YNHH is one of 32 organizations nationwide to receive federal Centers for Medicare and Medicaid Services funding to establish an AHC. The hospital is working with Cornell Scott Hill Health Center, Fair Haven Community Health Center, Project Access New Haven and the Healthier New Haven Partnership on the project.

Through the AHC program, patients on Medicare or Medicaid who visit YNHH adult and pediatric emergency departments, primary care centers and certain inpatient units, along with the Hill Health and Fair Haven health centers, may voluntarily participate in a screening about health-related social needs.

Patients identified as low risk based on the screening will receive information about community resources that can meet their specific needs, such as local food pantries or organizations providing transportation to medical appointments. Some high-risk patients may be assigned an AHC navigator. The navigator will take a more active role, such as helping the patient complete paperwork for food assistance or finding stable housing.

A key piece of the AHC program is software that interfaces with Epic and will allow YNHH clinicians to see if their patients who completed screenings have certain health-related social needs.

The project goal is to navigate more than 2,000 patients a year, and screen many more. In addition to supporting patients, the AHC program will yield data on how effective different types of assistance – information on resources versus navigator help – are in improving patients’ social determinants and, ultimately, their health.

For more information about the AHC, contact Karamo Kourouma, program manager, [email protected].