Improving Patient SDoH Needs through Standardized Screening and Referral

Clinic details

  • Private practice

  • Serves ~6,800 adults in Sedgwick County

  • Patient demographics are 87% Caucasian, 51% female

  • Staff includes:

    • 4 Physicians

    • 1 APRN

    • 1 PA

    • 2 RNs

    • 1 LPN

    • 4 MAs

    • 1 CAN

    • 1 scribe

Project Description

Goal: Improve the support of high-risk patients with SDoH-related needs through a standardized process for identification and referral.

Methods:

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

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

Results

As of December 2024 (nearly one year later):

  • Rate of screening improved by 30.3%, from ~17/6867 screens (measured by Z-code utilization) to 2028/6867

  • Positive screening rate for an identified need is approximately 4%

Next

Pharmacist Integration at an Internal Medicine Clinic