Enhancing Health through Social Determinants of Health Screening in Primary Care and Community Partnerships
Notice bibliographique
Résumé
Background: Screening for social determinants of health (SDOH) is not routine in primary care. The Calgary Foothills Primary Care Network (PCN) implemented SDOH screening in clinics to identify needs and partnered with Distress Centre/2 to navigate and connect patients to community resources, enhancing patient support and access to services. Approach: The one-year pilot project was grant-funded by the City of Calgary Addiction and Mental Health Strategy and involved a partnership between the PCN, Distress Centre Calgary 2 Alberta Service (herein referred to as 2), and Alberta Health Services (AHS). Key stakeholders from the PCN, providers, physician clinics, and 2 designed, implemented and monitored a closed-loop referral process to improve the identification of patients in need and the access and continuity of care between medical clinics and community services.Adult patients at participating PCN physician clinics were offered an SDOH screening questionnaire that assessed for financial, social, or safety needs. Patients who identified at least one need were offered a referral to 2 or a PCN social worker. The 2 service outreached to referred patients to complete a needs assessment and provide a list of available community resources. The 2 service completed a follow-up phone call and survey with the patient to assess if the resource(s) had met their needs. Finally, 2 closed the loopby sending a final disposition to the family physician. Results: Twenty-four member physicians at four clinics participated in the initiative. ,7 patients completed the screening questionnaire (84%), with 228 patients (n=20%) who screened positive for social and financial needs. This demonstrated the screening was an acceptable and appropriate setting to identify patients with SDOH needs. The questionnaire results showed that most needs were related to financial difficulty. Of the people who screened positive (n=228), 7% had difficulty making ends meet, 48% had trouble affording medications, 35% felt unsupported by friends or family, 4% had difficulty accessing food, and 2% felt unsafe where they were living. There were challenges connecting patients with resources, as only 56 patients who screened positive consented and were referred to 2. The 2 services successfully connected with 3 patients (23%) and provided patients with linkages to a total of 45 resources. 84% of patients indicated they felt comfortable answering the screening questions in the medical clinic. Implications: This initiative found that screening for SDOH in the medical home can effectively and appropriately identify people who may have financial, social or safety concerns. Furthermore, physicians and staff agreed and found value in screening for SDOH in primary care. However, there were gaps in connecting patients with identified needs to the 2-navigation service and linked to supportive community resources. This warrants further exploration with patients to understand their preferences, wants and needs for support and improve future interventions' design. By working collaboratively on this project, primary care providers, member clinics, and external partners learned more about the respective groups' services, roles and improved communication and integration of services. Future opportunities include simplified screening workflows, education and awareness about SDOH, organizational health equity measures and continued integration activities with patients and partners.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,013 | 0,019 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,001 | 0,001 |
| Études des sciences et des technologies | 0,007 | 0,003 |
| Communication savante | 0,004 | 0,003 |
| Science ouverte | 0,002 | 0,020 |
| Intégrité de la recherche | 0,002 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,009 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».