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Yale New Haven nationally recognized for health-related social needs screening

In 2018, Yale New Haven Hospital launched a program to help screen patients for non-medical issues that can directly affect health, such as financial difficulties, inadequate housing and lack of reliable transportation.

Since then, a team from Yale New Haven Health has refined and expanded its processes for gathering this health-related social needs (HRSN) information to help connect patients with services that can assist them. 

The health system recently received national recognition for this work, with an article in The Joint Commission’s November Journal on Quality and Safety. Article submitters include staff with YNHHS’ Population Health and Clinical Integration department and Office of Health Equity and Community Impact, along with Yale School of Medicine. 

“The collection of health-related social needs data has historically been inconsistent in healthcare settings,” said Polly Vanderwoude, executive director, Population Health and Clinical Integration, YNHHS, and one of the article authors. “We are very proud of the model we have developed to collect this important data set and believe we are one of the few health systems that have achieved HRSN screening at scale.  Ultimately, this data will be used to improve health outcomes and reduce health disparities.”

The processes the health system developed include a standard questionnaire for patients that is used within the last 12 months of an admission to any of our inpatient units, or within the past year of their last annual physical at Northeast Medical Group and Yale Internal Medicine primary care practices. Patients choose whether to answer the questions, which cover four core HRSNs: food insecurity, medical and nonmedical transportation, financial strain and housing stability. A workflow in Epic guides clinicians in asking the questions and entering information into participating patients’ electronic medical records. A social drivers of health Care Pathway has also been developed for care team members to access resources if a patient screens positive.

Since implementing the HRSN program, YNHHS’ annual screening rate for all active ambulatory patients increased from 0.4 percent to 15.9 percent. Of the patients screened, 10.7 percent had at least one health-related social need. The annual screening rate for inpatients grew from zero to 66 percentage points. The most common health-related social need in both settings was financial difficulties, followed closely by food insecurity.

Epic also helps specify whether patients are experiencing low- moderate- or high-risk HRSNs, which determines the amount and type of assistance they receive. That assistance may range from providing patients with low-risk HRSNs information about community resources such as local food pantries, to helping patients with high-risk HRSN apply for food assistance or find stable housing.

Read the full Joint Commission journal article at