With the rise of performance-based incentives, hospitals are facing a stronger reason than ever to connect their patients with community-based social services that may improve health outcomes beyond specialized medical care. The social determinants of health go far beyond basic needs that are easily identified by a look at a patient’s household income. They extend into factors like a lack of caregiver support in the household, a lack of education, transportation issues and substance abuse.

To be ahead of the curve when it comes to holistic patient care, hospitals should (1) connect with patients to determine their full scope of need; (2) form partnerships with local organizations to offer extended support; and (3) develop a systematic process for making referrals and tracking patient outcomes — to ensure that all factors are addressed.

Connecting with patients

In a recent survey of hospital executives conducted by GLG Social Impact, 83 percent of the hospitals surveyed felt that, over the next five years, it will become more important or critical to address the social needs of patients. In order to do this effectively, hospitals should be looking beyond the surface to identify the deeper needs for which each patient requires support.

You may know that some patients do not have enough to eat, but do you know why? Do those patients face food insecurity because they do not have a job, because they don’t know how to enroll in a state food program or because they are caring for others in their family first? Are your patients working but digging out of a poverty situation where a medical issue can put their future in jeopardy? Hospitals and clinical programs that are focused on patient-centered care are beginning to look past the obvious social need and ask guiding questions to navigate people to programs that can address the root causes of their need.

It isn’t always comfortable for hospitals to ask for information on root causes of the social determinants of health. Patients may not be naturally forthcoming about the challenges they face, and staff may not know how to ask questions with tact and sensitivity. Establishing clear roles and responsibilities — as well as a process for stepping patients through an identification of their needs — will help staff confidently direct patients toward programs that can help them. For example, a national effort such as the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences can give your organization a basis for a standard process and provide a framework for staff to ask and get answers to tough questions.

Forming partnerships

Needs in different communities across the United States may have a surface-level resemblance from one area to the next, but a deeper view reveals location-based variations. Weather, the local job market, access to quality education, access to health care and access to transportation can skew the needs of a local population. Partnerships with local organizations to develop and provide resource support can provide an advantage in addressing the specific needs of patients, beyond general poverty, in your community.

Your mission and goals most likely center around patient care, just as most nonprofit and government human services agencies focus on caring for their clients. This alignment in mission and mutual understanding of the social factors that affect your patients locally makes you a natural ally in identifying and managing patient needs.

Partner organizations can be singularly focused and specialized, or they can have broad coverage options that can help alleviate the work your team faces when navigating patients to social services. The partnership can be small in scale, such as working with a local temporary housing program to provide nutrition education for families. It can be a larger endeavor, such as partnering with local organizations to jointly gather information and determine the effectiveness of making community-based referrals for Medicaid patients in the emergency room.

Through key partnerships with local service agencies and better patient navigation to incorporate complex needs, your hospital will be better able to address the social determinants and medical determinants of health.

Monitoring activity

The time for speculative assumptions on patient need has gone by the wayside since the advent of value-based payment models. The new pressure to ensure healthy outcomes exerts pressure to implement a measurable system whereby your staff and patients can make trackable referrals to human services programs. The Centers for Medicare & Medicaid Services has made it critical for your organization to measure program effectiveness in terms of healthy patient outcomes.

Despite the increased pressure hospitals are facing, the GLG Social Impact study indicated that most hospitals are not alone in the need to improve their monitoring activities. An effective search and referral program will help your hospital not only make and track better referrals but also give your staff the ability to gather appropriate data to track key performance indicators and opportunities for program improvements.

In addition to tracking these indicators, measuring data can help your team put strong partnerships in place. For example, MedStar Health, a health care provider in Maryland and the Washington, D.C., region, saw that the demand for transportation among its patients had increased. This led to the formation of a partnership with ridesharing company Uber to ensure that patients who needed transportation to follow-up appointments were able to get a ride.

Beyond poverty

Your organization has an opportunity to look beyond surface-level poverty and support patients holistically through programs based on their specific needs. Now is the time to be at the forefront of patient-centered care by taking the time to develop a systematic approach to determining need, developing effective partnerships for patient success, and basing program decisions on measurable data.

For more information on this issue, see our Food Insecurity page with links to H&HN coverage and other AHA resources.

Chris Dunkin is vice president of Aunt Bertha in Austin, Texas.

The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.