Social determinants of health (SDOH) are conditions in the places where people live, learn, work and play that affect their quality of life, health risks and medical outcomes. They affect an individual’s ability to get the health care they need and maintain good health. For example, if you don't have access to a grocery store with healthy food, you are less likely to have good nutrition. That can raise your risk for health conditions like heart disease, diabetes and obesity, and it can even lower your life expectancy compared with those who do have access to healthy foods.

Northwestern Medicine screens for SDOH in primary care clinics and across all inpatient areas, focusing on a concise list of needs. Patients are asked questions related to the following factors, which are likely to impact their health:

• Medical access (patient has one or multiple established medical professionals for care)
• Ability to afford medication
• Transportation to medical appointments
• Access to nutritious food
• Safe housing
• Access to behavioral health care

Patients who identified with one or more of these SDOH needs, and who indicate they want help, first receive resources on their after-visit summary. Then a member of the Northwestern Medicine Outreach Team — comprised of community health workers, registered nurses and social workers — calls the patient, usually within 24 hours, to connect them with additional resources.

“The Outreach Team is dedicated to closing the gaps in care and equitably addressing clinical and social needs,” says Alesia O’daniel, an Outreach Team manager. “We connect the patients with the right resources at the right time to lessen barriers to wellness and stability.”

‘It’s OK to Ask for Help’

“Mental health is a very big part of what we’re addressing, but we help people with all sorts of needs,” says Fallon Lee, a community health representative. “We look at resources that are close to a person’s home, plus online and telehealth resources, and we collaborate with all the members of the Outreach Team to share resources and expertise.”

When the Outreach Team calls patients, they often learn about additional needs that weren’t indicated on the SDOH assessment. “Sometimes people are more comfortable sharing their needs with us over the telephone, because they may worry about feeling judged during an appointment,” Lee says. “I’m just a regular person talking to them and telling them it’s OK to ask for help.”

Transition of Care Outreach

In addition to following up with patients across Northwestern Medicine who indicate a SDOH need on the assessment, the Outreach Team is running a pilot program that proactively aims to help a subset of Northwestern Medicine patients. In the pilot, nurses conduct Transition of Care outreach calls within 48 hours of discharge for patients who frequently visit the Emergency Department at Northwestern Memorial Hospital, Northwestern Medicine Lake Forest Hospital and Northwestern Medicine Valley West Hospital.

“We do a Transition of Care screening, which includes reviewing discharge instructions and medications with the patient, and making sure they have appropriate follow-up care,” says Jeanne Borland, BSN, RN, Transition of Care nurse. “We also do a SDOH screening to identify any barriers to follow-up care.”

Teamwork Gets Food to a Family With COVID-19

Borland says that when patients indicate they have SDOH needs, she and other nurses on the team work with the community health workers to share resources to best meet patients’ needs.

This full support came in handy for a single mother who had COVID-19.

“We did the SDOH screening on a Friday and identified multiple issues, but food insecurity was the most urgent need. She said she would be OK over the weekend, and I told her I’d check on her on Monday,” Borland says. “I called her Monday morning, and both her young children were now COVID-positive, too, and she had no way of getting out to get more food.”

All the food pantries the Outreach Team found near the woman were closed, but Borland and her colleagues called them anyway, finally reaching the Pilsen Food Pantry. “As soon as I explained the situation, they arranged to have two weeks’ worth of food delivered to this young woman within 24 hours, and it was delivered by a medical student who was able to assess the patient and her children.”

Borland says when she followed up with the patient a few days later, the patient was so grateful.

“There was tons of fresh fruit and vegetables in the boxes, and it was just amazing,” Borland says. “That was a huge win for our team, and representative of what we can do when we pull together to take care of our patients.”

Learn more about Northwestern Medicine community impact.