Case Study: Incorporating Community Partners Into an Integrated Social and Behavioral Health Model to Address Food Insecurity and Housing

Project Activities

The LAC+USC ROOTS project team focused on three main activities during the grant year: improving the screening and referral workflow, expanding screening to additional clinic sites, and improving warm hand-offs to address identified needs.

Improving the screening and referral workflow

Over the course of the year, the ROOTS team worked to integrate screening as seamlessly as possible into each patient visit. Their goal was to routinize social needs screening as thoroughly as they had institutionalized depression screening, intervention, and follow up. They decided to screen all patients at every patient visit in order to routinize screening and capture changing needs.

“We decided that we would screen every patient at every visit for three main reasons.  First, and most importantly, we work with a safety net population that is in a lot of flux.  So even if a patient declines food insecurity or violence in the home 6 months ago, that may not be the case today.  Second, we’ve noticed that a patient’s readiness for disclosing this type of sensitive information takes time.  So, the first time we ask the question, we don’t always get the answer. Maybe it takes a year of relationship-building with new patients before they’re ready to disclose.  And finally, annual screens can be difficult to remember to do and so it’s easier to remember to screen if it’s part of the routine workflow.”

– LAC+USC Primary Care Director

Before the ROOTS partnership, LAC+USC added social needs screening to the health behavior and mental health screening conducted by certified medical assistants (CMAs) as part of patient intake.  CMAs have a standardized script that includes one question each for food insecurity and housing instability (see box). The questions are derived from existing screeners and condensed so every patient could be screened during intake. CMAs receive training on how to ask these questions but are not required to read the questions verbatim. Instead, they have the freedom to ask the questions in a manner they consider most appropriate and empathetic.

The ROOTS project team added responses to social needs screening questions into the patient’s record in the EHR, to match the process used for health behavior and mental health screening. They also asked providers to link responses to relevant ICD-10 z-codes (Z59.4 for Food Insecurity and Z59.0 for Housing Insecurity.)

If a patient answers Yes screens positive to either question, they are asked if they would like to be referred to resources. Approximately 10-20% of patients typically say they are not interested (which is lower than responses cited the literature).^[1]

Those who express interest are referred to a medical case worker who is part of the social work team, or to a Wellness Center patient navigator.  A message is simultaneously sent through the EHR to a member of the clerical staff, who adds the patient’s information (date of screening, screening results, and referrals made) to an Excel file.

To ensure providers are aware of identified needs and referrals made, the information is included as part of the problem list, and communicated verbally by a  CMA prior to the patient’s visit. This lets providers know that the issue has been identified and addressed. It also allows providers to take that information into consideration as part of the care they provide. They will also often include it in their notes so they know to follow up at subsequent appointments.

To monitor referral outcomes, a clerk calls patients who are on the Excel tracking list every two to four weeks to find out if the patient followed-up, and if they received the resources they needed. Initially clerks followed up until a patient affirmed that their needs had been met. However, during the grant year, the clinic decided that three follow-up calls were sufficient to provide a reasonable end point for engagement that did not overtax clinic resources.

_{[1] Knowles M, Khan S, Palakshappa D, et al. Successes, Challenges, and Considerations for Integrating Referral into Food Insecurity Screening in Pediatric Settings. Journal of health care for the poor and underserved 2018;29:11; Martel ML, Klein LR, Hager KA, Cutts DB. Emergency Department Experience with Novel Electronic Medical Record Order for Referral for Food Resoures. The western journal of emergency medicine 2018;19:6; Bottino CJ, Rhodes ET, Kreatsoulas C, Cox JE, Fleegler EW. Food Insecurity Screening in Pediatric Primary Care: Can Offering Referrals Help Identify Families in Need? Academic pediatrics 2017; Hassan A, Scherer EA, Pikcilingis A, et al. Improving Social Determinants of Health: Effectiveness of a Web-Based Intervention. Am J Prev Med 2015;49:822-31.}

Expanding to additional clinic sites

Once the screening process was working well in the first clinic site, the LAC+USC ROOTS team initiated screening in a second adult clinic. Although the two clinics were across the hallway from each other and shared some staff, the second clinic was a teaching clinic staffed by internal medicine residents rather than a staff provider. As a result, the ROOTS team found that they could not implement exactly the same process that they had developed in the first clinic, so they made modifications to match the processes and staff needs of the second clinic.

Improving warm hand-offs to address needs

The Wellness Center is a nonprofit organization located on the LAC+USC medical campus which houses community-based groups and organizations that provide support for social needs including housing support, produce distribution, healthy cooking classes, and CalFresh enrollment assistance, as well as chronic disease, domestic violence, and mental and behavioral health services.

Although the Wellness Center is on the same campus as the clinic and just a short walk away, it is not easy to find. To facilitate referrals to Wellness Center organizations, the ROOTS team first tried locating a Wellness Center patient navigator in the clinic to ensure warm hand-offs. Because of limited funding, however, the patient navigator was only available part-time, making it difficult to incorporate her into workflows in a routine way. Eventually, the ROOTS team secured funding for a full-time navigator dedicated to the primary care clinics.  They were also able to acquire a cell phone from the hospital, which enabled the navigator to respond to referrals while away from the primary care clinics. Following this change, referrals to the navigator jumped, and she soon found herself busy on a nearly full-time basis.

The second breakthrough for the LAC+USC ROOTs team occurred when the team lead learned that a Department of Public and Social Services (DPSS) CalFresh enrollment specialist working at the medical center, and that she was underutilized. (CalFresh is California’s Supplemental Nutrition Assistance Program.) Seizing this opportunity, they asked to have her spend part of one morning a week in the clinics  providing CalFresh enrollment assistance for eligible patients. Medical caseworkers and clerical staff who were following up with food insecure patients could make appointments for them with the enrollment specialist, and let them know ahead of time what documents to bring. Having an onsite enrollment specialist to whom they could directly refer patients decreased wait times for CalFresh benefits, while increasing the enrollment specialist’s CalFresh enrollment numbers, creating a win-win for the clinic, the Social Work Department, and DPSS.  Clinic staff particularly appreciated that the enrollment specialist was highly motivated to assist patients, sometimes rushing downtown to submit applications and returning with EBT cards within 24 hours.

The success of these efforts has earned the clinic local recognition for its work, including local media coverage; county leaders have also asked clinic staff to inform county efforts to implement social needs screening countywide. Finally, being able to provide patients assistance with food and housing needs has boosted provider and staff satisfaction.

Challenges and roadblocks

Although the LAC+USC ROOTS project had notable successes during the ROOTS grant year, it also experienced several challenges:

• Staff Turnover. High staff turnover required training new staff in social risk screening on a regular basis, draining resources that could be used elsewhere. This continues to be a challenge. Staff champions help mitigate this as does constant reinforcement that social needs screening is simply part of the job.
• Documentation in the EHR. LAC+USC’s EHR system, Cerner, displays the ICD-10 code for food insecurity, Z59.4 ‘food insecurity and inadequate water supply,’ only as inadequate water supply. Since team members enter the ICD codes manually and entering ‘inadequate water supply’ to code for food insecurity is counterintuitive, this initially created a barrier to capturing food insecurity data in a structured way in the EHR. Eventually, the team was able to get the county IT department to fix this issue, but it took approximately two years because the IT system spans the entire county and cannot be easily changed.
• Outcomes tracking. The team has yet to develop an integrated way to capture what happens after a referral is made. This data is kept in a protected Excel file. This enables the team to track the number of patients who are food insecure and their outcomes, but it is somewhat cumbersome, requiring extra data entry.
• Large geographic region of patients served. For patients who live close to the medical center, the resources of the Wellness Center are convenient. However, because LAC+USC primary care clinics draw patients from a large geographic region, staff often struggle to provide convenient resource referrals to patients who live far away.

Next Steps

Moving forward, LAC+USC Primary Care plans to continue to refine workflows and referral pathways, spread the program to their other pediatric and geriatric primary care clinics, and build deeper connections with community partners. As pioneers for this work in the county, the ROOTS program leaders will also continue to share insights and lessons learned as universal social needs screening spreads countywide.

LAC+USC Advice for Implementing Social Needs Activities

• Provide training and capacity building to prepare staff for this work. LAC+USC primary care leadership started building support for this work several years before the ROOTS grant. By providing staff education about the importance of addressing social needs to improve patient health, they created a shared understanding that social needs screening and referral activities are part of good primary care. They also provided skill-building training to demonstrate how to carry out screening in an empathetic way. These trainings were key to increasing buy-in and willingness to add new activities to existing workflows.

“When we first started doing this work, we heard about all sorts of potential barriers from staff: ‘We don’t have time,’ ‘It’s not our job,’ or other similar thoughts. We’ve seen a big change in attitudes since we started doing this work. Some staff have come the fullest swing of the pendulum – as if they found true meaning in their work because they’re developing deeper relationships with their patients. Now, if you’re not enthusiastic and actively participating in these conversations with patients, you’re more of the odd one out among the team.”

– LAC+USC Assistant Primary Care Director

• Engage frontline staff in designing the interventions. Including staff members who will do the work in program design will help ensure the program works. This will also help create staff champions who can build support for the program among their peers.
• Expand the roles of staff. Having the CMAs do the screening enhances their role on the care team. and motivates them  to work at their highest capacity.
• Share success stories. By starting each staff meeting with patient success stories and presenting data about the positive impacts of social and behavioral screening, the ROOTS project team helped staff see the impact of what they were doing, thereby helping keep motivation high.

“Staff sharing in that celebration and joy, ‘Okay, we made a difference. We actually changed somebody’s life preemptively.’ It’s just seeing that as a team, together; regardless of your role. It seems very impactful.”

– LAC+USC Provider

• Create team-based whole person care. A team-based care approach makes patients feel more comfortable because they interact with the same CMA and nurse every time they come in. This allows patients to build trust and rapport with staff as well as with providers, making them feel more comfortable with sharing information about social needs. This feeling of trust and comfort is furthered by having social workers integrated into care teams, providing a holistic patient experience.
• Embed partner agencies in your clinic. For LAC+USC, having a CalFresh enroller on site and a Wellness Center Navigator just a call away made all the difference. Both the CalFresh enroller and the Wellness Center navigator earned the trust of clinic staff because they were diligent and reliable.