NewYork-Presbyterian Works to Improve Patient Health by Addressing Social Needs

One of Dr. Dodi Meyer’s patients struggled with food insecurity and faced overall health and well-being challenges. Another patient lived in substandard housing, which increased her stress, reduced her ability to achieve restful sleep, and negatively impacted her health.

“As a primary care provider who’s been doing community-based medicine for the last 30 years, I was feeling very frustrated by seeing, over and over, the same illnesses presented to me with children and their families,” says Meyer, MD, a pediatrician and medical director of community health at NewYork-Presbyterian Hospital.

Equally frustrating was that she only had a few minutes to diagnose a child’s asthma or eczema. But even when she prescribed medication to address the condition, the child wouldn’t improve if they lived in a home that was full of mold or rodents, or had issues with heat or air conditioning.

Instead of just tackling these issues, Meyer wanted to help her patients address the root causes of illness such as housing or food insecurity. That would give each child the opportunity to achieve their maximum potential of health and well-being, she says.

For years, there have been efforts across NewYork-Presbyterian Hospital to address patients’ social needs, Meyer says. Then, in September 2022, the health system launched the Expanded Social Determinants of Health Screening in Emergency Department initiative, which screens for social challenges facing its patients. Today, the program exists across seven of the health system’s emergency departments (EDs).

Housing, Food, and Transportation Access Are Main Challenges

Social determinants of health (SDOH) are the conditions in which people are born, live, work, and age, and they have a significant impact on health and healthcare outcomes. To address the needs of its community, NewYork-Presbyterian Hospital conducted a needs assessment and determined that the top three social challenges are housing, food insecurity, and transportation.

Approximately 10 percent of the health system’s ED patients participate in the universal screening for SDOH after being referred by a provider, according to Patricia Peretz, MPH, who directs the hospital’s patient navigator and community health worker programs.

The screenings in the ED are conducted by patient navigators, who Peretz describes as representatives of the communities they serve. “They speak the language, and they’re really experts at building trust, which makes them uniquely positioned to understand the needs of our patients but also to support them to navigate the healthcare system…and to support their social needs as well,” she says.

A patient navigator initially meets the patient at the bedside in the ED and accesses evidence-based SDOH questions, which are embedded in the Epic electronic health record (EHR). There are three pathways that can be taken, based on the results of the screening:

1. No intervention: No identified social need or ED visits in the past year.
2. Patient receives a resource guide in the ED for an appropriate community-based organization (CBO): An identified social need, but no ED visits in the past year.
3. A hand-off to a CBO by a patient navigator and ongoing outreach to the patient until they successfully connect with the needed resources: Identified social need, plus one or more ED visits in the past year.

Early Results Are Promising

The program has resulted in screenings of more than 18,000 individuals across the system’s seven EDs. Of those patients, 17 percent had an identified social risk with about half of these individuals considered low risk. They received a list of CBOs to contact for support. The remaining half were classified as rising or high-risk and then connected with a CBO, with additional follow-up based on their needs.

Meyer says it’s too early to determine the health impact on patients, as the program was designed to help make an impact over months and even years. Still, she says the program is generally delivering “great results and [the health system] is proud of the support we’re able to provide the community.”

To support this work, the health system, in collaboration with Columbia University Irving Medical Center, received a five-year $4.5 million grant from the Centers for Medicare and Medicaid Services (CMS) to participate in the Accountable Health Communities (AHC) Model.

The model was established by CMS in 2016 to test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, and Children’s Health Insurance Program costs while maintaining or enhancing patient care. It focuses on five core areas, which include housing instability and quality, food insecurity, utility needs, interpersonal violence, and non-medical transportation needs.

Coding Remains a Challenge

From a health information perspective, there are three challenges NewYork-Presbyterian faces with this work: pulling the SDOH data from patients’ records; educating the hospital’s coders about where to find this information in patients’ charts; and interpreting the information for billing purposes.

Automatically getting SDOH information added to patient claims is the goal, says Amelia Shapiro, vice president of the health system’s Dalio Center for Health Justice. She’s working with revenue cycle management colleagues to pull the data directly into the patient record, which would translate into a Z code on a health insurance claim. Z codes, which are included in ICD-10-CM, can be used to capture standardized SDOH information.

Currently, coders are looking for SDOH information about patients and adding it to patient claims manually. While the health system can receive messages from CBOs once they have met with a patient or addressed their needs, the information isn’t automatically documented in the EHR.

Still, There Are Successes

NewYork-Presbyterian Hospital works closely with CAMBA, a Brooklyn-based nonprofit that serves more than 65,000 individuals and families across the city. According to Ashley Marimón, LMSW, vice president of special projects at CAMBA, the program shows that patients are eager to access social services and resources when the process is streamlined and client centered.

Marimón gives an example of a patient with diabetes who was having trouble controlling their A1C levels, which led to multiple ED visits. The patient is now involved with CAMBA Drive-Down Diabetes, a multi-faceted public health program that involves a variety of interventions, such as connecting with a registered dietician and a personal trainer and access to exercise equipment.

The patient also has access to CAMBA’s food pantry and Homebase, a program that assists with housing loss prevention, another concern for this patient; that’s in addition to support for paying back money owed on rent and utility bills.

“People want to improve their health and well-being, but it can be very challenging to navigate how to do this,” Marimón says. “What works is when there’s a partnership like ours, in which NewYork-Presbyterian educates patients about CAMBA services, refers those [who] are interested, and CAMBA is able to initiate contact within 24 to 48 hours. We catch the person shortly after their ED visit, when their health and needs are top of mind, and we encourage them to begin working on their goals right away.”

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Aine Cryts, based in Kennebunk, ME, is a healthcare writer who is pursuing a master of public health degree focused on SDOH and health informatics.

AHIMA is playing a key role in how social determinants of health (SDOH) data is collected, shared, and used. For example, the Data for Better Health initiative provides tools, resources, and education to support a better understanding of the importance of SDOH data and how it can be used to improve health and healthcare outcomes