Social Determinants of Health and Care Coordination for Total Hip Arthroplasty Patients

Abstract

The overall health and well-being of all patients is impacted by living and working conditions typically referred to as social determinants of health (SDOH). Recognizing the upstream impact these conditions may have on individual health care outcomes, the project organization utilizes a social care integration tool which connects the electronic health record (EHR) with local community partners and resources via the Unite Us platform. This evidence-based quality improvement project was designed to develop a clinical workflow to incorporate assessment of SDOH needs for patients scheduled to undergo a Total Hip Arthroplasty (THA) surgery and who are scheduled for a medical consult in the Pre-Admission Testing (PAT) Clinic. Patients who screened positive for unmet social needs including either food insecurities or transportation concerns were referred by the PAT Clinic Nurse Navigator to an appropriate community partner via the Unite Us dashboard utilizing the NCCARE360 platform. Chart reviews were conducted to confirm successful completion of the SDOH screening and documentation on the EHR flowsheet, with results visible on the patient storyboard for clinicians to easily view in the EHR. Findings identified 39 THA patients successfully screened, documented, and assessed for SDOH with five patients verbalizing unmet social needs. Referrals were successfully submitted and accepted by community partners for three patients. Although the number of patients with identified social needs was small, the PAT Clinic staff successfully implemented a screening and referral workflow that can be expanded to other surgical patent populations seen in the PAT Clinic.