MRT Innovations in Social Determinants of Health Initiative

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

BronxCare is a large 972 bed community hospital serving the South Bronx community. In addition to Emergency Department and inpatient services we also provide care through a large network of Federally Qualified Health Centers. As the largest Medicaid provider in New York State our mission is to provide quality and compassionate care to a very high risk population. We address issues germane to a patient population that has high rates of poverty, low health literacy and language barriers that make accessing health care difficult. Given that social determinants of health have such a huge impact upon low–income populations, the need to develop SDOH screening and resource tools is particularly crucial to the care delivered at our institution.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

We are in the development phase of our Social Determinants of Health (SDH) project. We have formed a SDH committee consisting of the Chair of Pediatrics, the OPD Medical Director, OPD Administrator, Director of Special Programs and Director of the Asthma DSRIP Program to oversee the development of the project. Two Summer medical student volunteers are putting together the details of the program under the supervision of the Chair and SDH Committee. We are planning to implement a program, initially, in our main ambulatory pediatric clinic. We will center our program on the placement of a resource table in the clinic waiting room. We will use validated screening tools for SDH´s such as food insecurity and are identifying other screening tools that can be effectively utilized. We will also be using electronic apps to quickly identify and connect patients with resources such as a food pantry app that identifies food pantries in the local area. The placement of the resource program in the waiting area serves several functions; it normalizes and destigmatizes addressing SDH as part of pediatric care by it´s occurrence out in the open, it will take the task of identifying and addressing SDH from the clinicians who are already hard pressed in terms of time and productivity, and finally it will allow families to make productive use of their time while waiting to see their provider. In addition to a screening tool that will be initially done on paper and eventually incorporated into the electronic medical record; patients will be presented with a list of SDH´s (such as housing insecurity, mental health issues, interpersonal violence, smoking cessation, substance abuse) and asked if they would like to receive further information on any of the listed areas. Information will be provided through either printed materials or patients will be able to explore resources on a computer with the assistance of staff. This will be done in a manner to insure confidentiality. A list of issues identified and referrals made will be generated and presented to the provider to allow continuity from the resource table to clinical care and this will be incorporated into the medical record. Any issues that require immediate attention will be referred to the dedicated clinic social worker. The table will be manned by residents, medical students and other students such as social work students with the overall project being under the supervision of the OPD Medical Director. A training manual is in the process of being created and will be utilized to train those manning the table. Pediatric residents will participate in this project as part of their month long community health rotation and will be responsible for maintaining it and supervising medical students and other trainees. Eventually, because of it´s low resource utilization it will be replicated in other OPD settings, the Pediatric inpatient floor and Emergency Department.

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