A new electronic health record-integrated platform is making strides in identifying and addressing social needs among African-American adults in Baltimore. The initiative, implemented across five primary care clinics and partnered community organizations, targets individuals from socioeconomically challenged neighborhoods.
Study Design and Implementation
Conducted as a randomized controlled trial, the study engaged 1,648 eligible patients, with 92 participants enrolling over six months. The digital platform included clinical decision support and a closed-loop referral tool, aiming to streamline the assessment of social needs and facilitate navigation to appropriate services.
Participants and Intervention Outcomes
Participants were divided into intervention and control groups, with the intervention group further categorized based on the platform’s assessment of their social needs. Results indicated a significant reduction in documented social needs among those identified by the platform as requiring further assessment and support compared to the control group.
- The platform effectively identified high social need cases requiring additional support.
- Intervention Group B showed a higher decrease in social needs compared to the control.
- Integration with existing health records facilitated better tracking and intervention.
During the initial six months, 25 out of 44 intervention participants did not require further assessment, while 19 were identified for additional support. Among these, a notable percentage experienced a decrease in their social needs, highlighting the platform’s efficacy.
The study demonstrated that embedding social needs assessment tools within electronic health systems can lead to more accurate identification and effective intervention for patients facing socio-economic challenges. This approach leverages existing health data to provide targeted support where it’s most needed.
Structured assessments and integrated referral systems empower healthcare providers to address social determinants of health proactively. By facilitating connections to community-based organizations, the platform bridges gaps between clinical care and social support services.
Future efforts should focus on scaling the platform to additional clinics and diverse populations, ensuring broader access to social needs assessments and interventions. Continuous evaluation will be essential to refine the tools and maximize their impact on patient outcomes.
The integration of social needs assessments into electronic health records represents a practical step towards comprehensive patient care. Healthcare systems aiming to address social determinants can benefit from similar digital solutions to enhance service delivery and patient well-being.
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