The HHMHC faced challenges in consistently addressing SDOH during patient visits. Patient visits in our program are either “pop up” patient encounters in partnership with local public schools, or patient encounters on the mobile health unit. While our pop-up clinics utilized verbal SDOH screenings and connected patients to resources through a community health worker (CHW), clinicians on the mobile health unit did not have a consistent, systematic process for SDOH screening. Additionally, the existing screening questions were not specific to the pediatric population. Finally, there was no organized resource guide available for patient referrals when SDOH screening results were positive.  

Our team recognized the urgent need to develop a process for SDOH screening and referral. First, we completed a literature review to determine the most impactful and culturally sensitive questions to screen our patient population. We interviewed our stakeholders to better understand the challenges and best strategies for implementing a new SDOH screening workflow. We worked with our clinical informatics team to develop a SDOH flowsheet that would integrate into our EHR. This was critical in order to consistently document and track our SDOH screening and the outcomes.  

Lastly, through extensive community-mapping, we developed a list of resources that we could use for patient referrals for positive SDOH screens.   Through our quality improvement process, our outcomes were: The development of a nonverbal SDOH screening questionnaire which focuses on access to food, housing, transportation, childcare, and financial stressors. Providers can enter the results of the patient screening tool into a flowsheet in the EHR, and this will flow into the provider notes in the clinical encounter. The development of an organized resource guide, divided into different zip codes, that providers can use to refer patients to specific resources based on positive SDOH screening (i.e food pantries, resources for transportation and housing). 

Our next steps are to collect provider feedback for this new process and to develop a system to track patient outcomes after they are referred to community resources.  

Learning Objectives: Describe the process of developing an SDOH screening tool for a mobile health clinic. Explain strategies for supporting and integrating an SDOH screening tool into mobile health clinic workflows. Discuss “next steps” for evaluating the impact of a SDOH screening tool and associated resource guide in a mobile health setting.