Addressing Patient SDoH through Standardized Screening and Referral

Clinic details

  • 6 attending physicians

  • ~40 resident physicians

  • 1 dietician

  • 1 social worker (MSW)

  • 1 pharmacist

  • 1 LPNs (2 more as “transitions of care” LPNs in hospitals)

  • 5 MAs

  • 1 Community Health Worker

Project Description

Goal: Improve the capacity of the diabetes workforce to address Social Determinants of Health (SDoH)-related barriers. Improve acceptability and quality of care individuals with diabetes.

Methods:

1) Assess current workflow, technology resources, as well as data entry and abstraction methods.

2) Identify barriers and facilitators to screening and referring patients with SDoH needs.

3) Adapt workflow to prioritize addressing SDoH needs. Develop a reimbursement strategy for financial sustainability.

Results

As of XXXXX, XXXX:

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Gestational Diabetes Screening in a Family Medicine Residency Clinic