The health system’s model will enable primary care practices to effectively screen for social determinants of health (SDoH) to improve health equity in vulnerable communities.
Patients’ struggles with SDoH such as housing, food insecurity, and transportation, are frequently overlooked despite the significant role they play in mental and physical health. To better identify and address these issues, Equality Health, a Phoenix-based whole-health delivery system, has implemented targeted initiatives with community partners to improve outcomes.
Primary care practices will play a critical role in the health system’s care delivery since they have existing relationships with the patients, Equality Health recently announced. Participating primary care practices screen patients for social needs and cultural preferences with Equality Health’s Social Cultural Risk Assessment (SCRA) survey, which evaluates patient’s housing, transportation, food insecurity, cultural beliefs and preferences with health care and medications, behavioral health, physical activity, sense of wellbeing, and spiritual needs. Patients will complete the survey as they wait for their appointments.
Those who screen positive for a social need will be connected to community-based organizations and other local support. “We have been using SCRA for more than two years, and it has significantly helped us improve the health and quality of life for our patients, many of whom are underserved,” Nabor Rios, M., MS, PA-C, associate medical director, Happy Kids Pediatrics, said in the announcement. “We’re able to assess patients’ social and cultural needs and connect them to the appropriate resources without putting undue burden on our providers. This straightforward process and workflow has operationalized cultural care in our practice and enabled us to play a larger role in our patients’ outcomes.”
Primary care practices participating in the SCRA program are required to complete onboarding training on cultural awareness as well as appropriate SDoH coding. The program is currently used in more than 1,400 primary care practices and completes more than 3,000 assessments per month, which helps forecast emergency room costs while mapping to existing ICD-10 codes to lessen administrative burdens, noted Equality Health.
To encourage continued use of the SCRA program, Equality Health also offers quarterly financial incentives to primary care practices that administer the survey.