Implementation Toolkit Social Determinants of Health Screening and Referral The purpose of this document is to share the processes designed, and lessons learned, from the Caring Beyond Healthcare pilot project.

Our hope is that hospitals and community service organizations across the country can use the toolkit to efficiently undertake similar projects.

www.Medicare.QualisHealth.org/CBHC

The Robert Wood Johnson Foundation’s 2014 County Health Rankings Model estimates that only 20% of health outcomes can be attributed to clinical care. Non-medical factors account for the other 80%—including social and economic factors (40%), physical environment (10%), and health behaviors (20%).

The Caring Beyond Healthcare pilot project was conducted by Qualis Health in Idaho and Washington, using Special Innovation Project funding provided by the Centers for Medicare & Medicaid Services.

Participating hospitals were paired with a local community service hub (such as the Area Agency on Aging). Hospital staff asked patients about potential social determinant of health (SDoH) needs and forwarded the information of at-risk patients to the community hub—who then matched the patient to appropriate non-healthcare services.

For details about the project’s results and findings, see page 20.

Further Assistance Brooke Benton, MPH Quality Improvement Consultant

Traci Treasure, MS CPHQ LNHA Quality Improvement Principal

Seattle, Wash.

brookeb@qualishealth.org 206-288-2412

Boise, Idaho

tracit@qualishealth.org 208-383-5947

www.Medicare.QualisHealth.org/CBHC This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-CBHC-QH-3527-10-18

Table of Contents 1. Start Where You Are ................................................................................................ 1

Table 1: Questions to Consider ......................................................................... 1

2. Get Your Hospital on Board .................................................................................... 3

Leadership ................................................................................................................. 3

Affected Staff ............................................................................................................. 3

All Staff ...................................................................................................................... 4

3. Partner with a Community Hub ............................................................................... 5

Identify the Desired Partner ....................................................................................... 5

Recruit the Partner Organization................................................................................ 5

Example 1: Partner Recruitment Leave-Behind ................................................. 6

What’s In It for Them? .......................................................................................... 7

4. Develop an Implementation Plan ............................................................................ 8

Keep Everyone in the Loop ........................................................................................ 8

But, Protect the Data ............................................................................................ 8

Define the Goals and How They Will Be Measured ................................................... 9

Choose Which Information to Collect ................................................................... 9

Table 2: Sampling of Project Metrics ............................................................... 10

Example 2: Caring Beyond Healthcare Screening & Referral Tool .................. 11

Table 3: Evidence-Based Screening Tools Related to SDoH Needs ............... 13

Set Up a Means to Document and Share Each Record ..................................... 14

Plan for Alternate Languages ............................................................................. 15

Example 3: Caring Beyond Healthcare Screening & Referral Tool, in Spanish ........................................................................................................ 15

Select Patient Population(s) ..................................................................................... 16

Develop Patient-Facing Resources .................................................................... 17

Example 4: Project Introduction for Patients .................................................... 18

5. Conduct Pilot Testing ............................................................................................ 19

6. Kick Off the Project ................................................................................................ 19

7. About the Caring Beyond Healthcare Pilot Project ............................................. 20

Qualis Health 1 Implementation Toolkit: SDOH Screening & Referral

1. Start Where You Are Before you jump into a new intervention, take some time to document the existing situation at your hospital. What elements are already in place? Are there any potential synergies or pitfalls related to your current processes?

Once you have completed your exploration, try to identify the elements most likely to encourage—or raise concerns among—hospital leadership, affected staff, community service providers, and patients.

Table 1: Questions to Consider

1. Does anyone at your hospital ask patients about their social determinants of health (SDoH) needs?

If no: What are the stumbling blocks?

Do people in different departments or job roles have different reasoning?

If yes: Is the same set of questions always asked, or is the inclusion/exclusion of particular questions determined on an ad hoc basis? Is the responsibility to ask about SDoH needs assigned to a specific job role, at a particular milestone during an inpatient or ED visit? If not, gather example situations and indicate who asks the questions when. Are some patients more likely to be asked? If so, what are some of the triggers or flags that alert staff to inquire about SDoH needs? Are certain departments or individual staff members more likely to ask about SDoH? Why is that? And why are others not as likely? Are the answers documented?

If no: What are the stumbling blocks?

If yes: Is that done consistently? Where are the answers kept? Can the information be easily shared/retrieved? During the last 12 months, how many patients were found to have each type of SDoH need?

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Table 1, continued

2. Do patients receive any information and/or resources from your hospital related to SDoH needs?

If no: What are the stumbling blocks?

If yes: Is the provision of this information a result of SDoH needs screening?

If no: Identify the other ways in which patients may access the information.

If yes: Gather a few examples.

3. Do hospital staff contact any community services on behalf of the patient? If no:

What are the stumbling blocks?

If yes: What is the process for giving the information to the service agency? Is the process the same for all agencies? List all the agencies that receive these kinds of referrals from your hospital and the types of services they provide.

• If the agency does not provide services directly but instead connects with a network of other organizations, describe the network as well.

How many referrals were given to each agency during the last 12 months? Are these agencies satisfied with the referral process? Has the hospital experienced any challenges related to any of these agencies? Have the agencies always been able to provide/locate the type of service needed? If not, document the unmet need.

4. Are there other community service providers who may be able to supplement or replace the existing referrals? (See Partner with a Community Hub, page 5.)

5. Is there a means to determine whether the patients’ SDoH needs were met after they were discharged?

6. Is there a means to determine whether SDoH needs screening and referrals impact rehospitalization rates or other healthcare spending?

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2. Get Your Hospital on Board While you may recognize the value of this work, you will not be able to do it on your own.

Identify the ways that this project fits (or does not fit) into your hospital’s current priorities and mission-critical needs. You will need precious labor resources to do this work. Is the timing right?

Leadership The odds of success will be improved if you have buy-in from your hospital leadership. In addition to the points listed below, what elements of the project would be compelling to individual members or the full leadership group?

• Partnering with organizations designed to provide non-medical services helps patients get access to the supports they need and prevent future health crises. Early support also frees up hospital capacity which can improve throughput and cash flow, especially for payment models such as ACO and BPCI.

• Stronger links with community organizations translates to more fulfilled employees, a higher regard among the public, and more robust responses to grant opportunities.

Affected Staff Engaging front-line staff in early project planning will encourage buy-in and facilitate the design of appropriate workflows. Who has the motivation to champion this cause and the influence to sway others?

Before asking staff to collect personal and sensitive information from patients, it is important to explain to them how the information will inform care and services, then ultimately improve health outcomes. Knowledge of the bigger picture will enhance their comfort with, and competency in, the project. Consider asking your identified resource/referral “hub” organization to provide an in-service education session that

“It really opened leaderships’ eyes to a big gap that we had in our system and a need for our patients, so there’s commitment from leadership to carry this forward…and that’s a beautiful outcome.”

Susan Frederick, MSN RN CHFN Heart Failure Program Coordinator Legacy Salmon Creek Medical Center Vancouver, Wash.

“One of the great successes of this project was that it got all of us in our systems talking about social determinants of health and why they matter and why we need to track them and address them.”

Christine Packer, MEd Chief Transformation Officer Clearwater Valley & St. Mary’s Hospitals (rural Idaho)

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outlines the network of services available to patients screened and identified as having SDoH needs.

Throughout process workflow testing, provide on-going coaching support and seek continuous feedback from impacted staff.

All Staff Will you include a broader campaign to notify all staff or even the public that your hospital is working on connecting people to community-based resources? If you and your hospital leadership determine that a broader message is needed, engage your staff education, internal communications, and public relations teams.

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3. Partner with a Community Hub

Identify the Desired Partner While referrals related to patients’ SDoH needs could be given to any number of organizations, the hospitals participating in the Caring Beyond Healthcare pilot project were each linked with a single organization located in their communities.

First, it was easiest to develop a single system for referring the patients; there were no choices to be made by hospital staff when sending the referral or following up later. Second, in order to successfully meet the demands of a potentially large new set of clients, the community organization needed sufficient infrastructure and capacity—something that not all individual service agencies could provide.

Organizations that can meet these criteria, plus have a mission to act as a hub to a broad array of non-medical social services, often include Area Agencies on Aging and Area Disability Resource Centers. Your community may be home to other potential candidates for this role.

Recruit the Partner Organization Personal connections are always helpful, so determine whether any hospital staff already have an existing relationship with the target organization. Involve them in the discussion of potential benefits, and in identifying the right person at the organization to contact.

Before approaching the organization, identify:

• What you have to offer that would benefit them (see suggestions on page 7)

• The anticipated roles and responsibilities of each party, including the degree to which the target organization will contribute to developing project-specific interventions, workflows, patient selection criteria, metrics, and reports

• Who will be the organization’s main point of contact at the hospital

You can use those ideas to develop talking points for a meeting and a “leave-behind” document (see Example 1) that can be used to promote the project to others within the target organization. The example document was used for engaging hospitals in the Caring Beyond Healthcare pilot project; you will want to develop talking points that are specific to your community partner.

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Example 1: Partner Recruitment Leave-Behind

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What’s In It for Them? • Evidence of impact

Your hospital can provide project data (people served, healthcare dollars saved) to help the organization shine a light on its own work.

• More information about their existing clients Your hospital could notify the organization, in real-time, when their clients are admitted or discharged, and provide regular reports of their clients’ aggregate utilization and rehospitalization rates.

• New clients Some of the patients referred from the hospital may not have used the organization’s services previously. This is particularly important because many organizations’ funding levels are determined by the number of people they serve.

• Better understanding of healthcare The organization might not have “insider knowledge” about the issues and concerns facing healthcare providers—and by extension, their clients with chronic healthcare needs.

• Opportunity to share skills and goals with a new audience In the Caring Beyond Healthcare pilot project, the participating organizations helped hospital staff get over their reluctance to ask SDoH-related questions and use the screening tool in a skillful way. Some were also involved in developing the pilot processes. Finally, they presented to groups of doctors, nurses, and other hospital staff regarding all the ways in which they connect clients to community services.

• Synergies with other projects If you know that the organization is working on other initiatives that could benefit from hospital involvement, mention it!

• Funding You could create a shared payment model based on a capitated/managed patient population and results from your initial pilot testing. Or, are there grants or other sources of funding that align with the project goal?

• Something unique to your circumstances Is there something about your hospital or community that offers another benefit to the target organization?

Community hub participants’ feedback:

Before the Caring Beyond Healthcare project, there were pockets throughout one rural community without any home healthcare services or food bank deliveries. By repeatedly pointing out these underserved areas—and the numbers of specific individuals who would have to do without—the AAA were able to shine a light on this problem and get it resolved.

Another community hub expressed surprise at how much learning was generated (for both hospital staff and hub staff) from a project that appeared so simple.

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4. Develop an Implementation Plan In the Caring Beyond Healthcare pilot project, the following four considerations rose to the surface as being crucial to the success of each partnership:

• Communicating with the team

• Defining goals and metrics

• Creating systems for performing the SDoH needs assessment

• Selecting a patient population Each element is described in detail below.

Keep Everyone in the Loop While the leaders of your hospital and the community hub will not need to be briefed on every detail of the project planning and implementation, it is likely that they will want to be informed at key milestones. Develop a short list of important milestones and when you are close to meeting them, schedule a meeting or write a project update to keep the leaders informed.

Primary contacts at both organizations should be in close communication throughout the planning stages and early implementation. How often will you call or meet with each other? Frequent check-ins will ensure that the project is launched on time, any issues that pop up are resolved quickly, and successes are celebrated regularly.

A few key milestones could also be used to trigger broader reporting within both organizations and even the media. How will you promote your project’s successes?

But, Protect the Data Process measures (“we screened 42 patients last week”) and de-identified data do not need special protection.

But how will you share patient-specific, identifiable information between organizations? At a minimum, the hospital will need to give the community hub each of the completed SDoH screening forms.

Is your EHR up to the task? If not, what other secure digital technology is available to you? For example, some organizations use a separate case management software that can be accessed by users from other organizations.

You don’t need to wait until you have a technology with all the bells and whistles. Start your pilot implementation with simple methods—such as faxing the paperwork—and consider investing in another solution after the project is off the ground.

Regardless of the technology used, your hospital and the community hub may want to develop a formal data-sharing agreement that is signed by both parties.

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Define the Goals and How They Will Be Measured Is your intent that:

• All patients with food insecurity are connected to supports?

• The rehospitalization rate across all Medicaid patients drops by 10%?

• 80% of referred patients are contacted by the community hub within 48 hours of discharge?

Clearly, the data you would need to collect, and the workflow you design, depend upon your goals. Do both organizations share the same goals? Have you asked staff in several departments or roles for their ideas?

Take the time to define the primary aims of your project (both short-term and long-term, if necessary) and connect them to metrics that are practical to collect. Project measures could include any of the ideas listed in Table 2 as well as those tailored to your specific needs.

Choose Which Information to Collect It is not necessary to create an SDoH needs screening tool from scratch; many are already in use. Together, the hospital and community hub should review existing forms and note what they do or do not like about the content.

• Your own forms: Is your hospital already screening for SDoH needs? Does the community hub already receive referral forms from another partner?

• See Example 2 for the screening content used by many of the Caring Beyond Healthcare participants. The form is downloadable from www.Medicare.QualisHealth.org/CBHC

• Review the screening tools found in the evidence-based research projects listed in Table 3.

Refer back to the goals and metrics you developed. Will you need to include any specific fields in the screening tool in order to collect the required data?

Refine the wording. Rely on the expertise of your community hub and experienced staff within the hospital to check that all the content is written in a matter-of-fact, sensitive tone that will elicit the types of responses you are working toward.

• Sample language, and suggestions for evaluating the wording, are included in the Health Leads Screening Toolkit at https://healthleadsusa.org/wp-content/uploads/2016/07/Health-Leads-Screening-Toolkit-July-2016.pdf

• The “empathic inquiry” technique is designed to make an interview feel less like data collection and more like an opportunity to connect with the individual patient; see this video example developed by the Oregon Primary Care Association: https://www.youtube.com/watch?v=9rfmfsMMeEU

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Table 2: Sampling of Project Metrics

• Number of admitted patients within the targeted population - Of that number, those: Who refused to be screened and/or refused referral to the community hub For whom SDoH screening was completed within the targeted timeframe (i.e.,

12-48 hours prior to discharge)

• Of the screened patients, those who were identified as having SDoH needs

• The distribution of patients identified as having each type of SDoH need included on the screening form

• Of the patients with identified needs, those who were: - Successfully contacted by the community hub within the targeted timeframe (i.e.,

2-3 days after discharge) - Not reachable via the phone number collected by the hospital

(This was the most common barrier to follow-up activities that occurred in the Caring Beyond Healthcare pilot project.)

• Of those contacted, the number who received social services

• Community service provider’s retention of new clients after referral from the hospital

• Names of all the staff members who attempted each screening and/or follow-up (especially during the early phases, to see if there are opportunities to improve training and/or identify elements that facilitate/complicate the work)

• Rehospitalization rates among the targeted population, during the 6-12 months prior to implementation and at regular intervals thereafter

• Number of clients, overall, who were connected to social services by the community hub, during the 6-12 months prior to implementation and at regular intervals thereafter

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Example 2: Caring Beyond Healthcare Screening & Referral Tool

A PDF of this tool is downloadable from www.Medicare.QualisHealth.org/CBHC

(Side 1)

Example 2, continued

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(Side 2)

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Table 3: Evidence-Based Screening Tools Related to SDoH Needs1

Tool Name Downloadable Tool (if available)

Article Describing the Tool and Intervention Results

BOOST 8Ps https://www.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/8ps_riskassess-1.pdf

Login required https://shm.hospitalmedicine.org/acton/fs/blocks/showLandingPage/a/25526/p/p-0076/t/page/fm/0

HOSPITAL https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2498847

IHI Readmission Risk Assessment (STAAR)

Login required http://www.ihi.org/resources/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx

LACE Print version https://greatplainsqin.org/wp-content/uploads/2015/01/Lace-Index-Scoring-Tool.pdf

Online version http://hsprn.ca/lace2/lace_app_desktop.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5362694/

PAM Available for purchase https://www.insigniahealth.com/products/pam-survey

http://www.insigniahealth.com/research/archive/

Psychosocial Acuity Scale

https://www.michigan.gov/documents/mdch/FORM_-_Client_Acuity_Scale_Worksheet_1_225816_7.pdf

Available for purchase https://www.tandfonline.com/doi/full/10.1080/00981389.2014.898726

1 Links to each of these resources are also available at www.Medicare.QualisHealth.org/CBHC

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Set Up a Means to Document and Share Each Record As discussed on page 8:

• Privacy concerns must be addressed related to how the hospital and community hub will handle the patients’ responses to the SDoH screening

• You do not need to wait for a “perfect” technological tool in order to start pilot testing the intervention

• It is recommended that the hospital and community hub establish a formal data-sharing agreement

Regardless of whether you will be handwriting responses into a paper form or clicking checkboxes within an EHR, aim to make the interface as user-friendly as possible so that you increase the data’s accuracy and decrease the amount of time it takes to record it. Is there enough space to write in responses? Are the questions sequenced logically? Is the font large enough to be read by everyone?

Consider the workflow. If you will be starting with a subpopulation of patients, how will the hospital staff know when an eligible person has been admitted? Who, exactly, will be asking the questions, and at what point?

Caring Beyond Healthcare participants found that patients were most likely to be matched to appropriate services if the screening was conducted, and the referral information sent, approximately 12-24 hours prior to discharge.

What will the workflow be at the community hub? Will the data be delivered in the same way as other referrals, or will different steps be required? Who, exactly, will be processing the referrals? How much time is allowed to lapse before first making contact with the client? While most of the community hubs that participated in the Caring Beyond Healthcare pilot project phoned the client shortly after discharge, some first met the client at the hospital. This extra step helped the client form a personal relationship with the community hub and improved the odds that they would accept services offered.

What types of follow-up information should be sent from the community hub to the hospital, and how often? (Refer back to your project goals and metrics for guidance about follow-up data requirements.)

During the CBHC pilot project, hospitals first found it easiest to perform the screening upon admission, or as soon as reasonable thereafter.

However, staff at the community hub were then left with the unknown variable of when to phone the patient—too soon after receiving the referral and the patient might still be in the hospital; too late after discharge and the person may already have:

• Experienced preventable difficulties, and/or

• Forgotten that they agreed to the intervention at all

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Plan for Alternate Languages If the selected patient speaks a language other than English, it can be helpful to provide a paper version of the screening questions in the appropriate language. In that way, the patient (and/or the family caretaker) can follow along more easily—even if there is a translator on hand to ask the questions verbally.

A Spanish version of the screening tool used by many of the Caring Beyond Healthcare participants is provided in Example 3. It may be downloaded from www.Medicare.QualisHealth.org/CBHC

Example 3: Caring Beyond Healthcare Screening & Referral Tool, in Spanish

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Select Patient Population(s) Your initial testing of the project should focus on a small handful of patients, over a small period of time. (Pilot testing is discussed in more detail starting on page 19.)

After all the kinks are worked out, which patients do you intend to screen for SDoH needs?

• Everyone admitted?

• Everyone over a certain age?

• Just those who are uninsured, insured by Medicaid, or with private insurance?

• Just those admitted for a specific condition?

• Only the “super utilizers”?

• Do your project goals and metrics point you toward selecting a specific sub-population of patients?

If you decide to target a subpopulation, develop a system to alert the people who are tasked with performing the SDoH needs survey. For example, it may be helpful to choose a population that is easy to identify based on the normal workflow for the patient, such as when they are admitted to a certain location or service line. Then, work with staff in that area to test how the screening will be incorporated into the workflow on that unit.

The CBHC project was funded by Medicare. Thus the populations targeted by the participating hospitals included, at a minimum, patients who were dually enrolled in Medicare and Medicaid. Some participants aimed to screen everyone.

A few lessons learned:

• A large urban hospital initially focused on patients dually enrolled in Medicare and Medicaid. They discovered, however, that the needs for this population were so high that it was difficult to show an impact. They experienced more success when they targeted patients who were potentially in danger of, but not already in the midst of, a crisis. In these cases, social services provided enough resources to tip the situation back onto stable ground.

• A small critical access hospital planned to screen all patients, then refined that population definition to all inpatients rather than including patients in observation status. This definition also proved challenging until they moved the timing of the screening closer to time of discharge (after the patient’s status had been determined).

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Develop Patient-Facing Resources Healthcare professionals don’t often ask the kinds of questions included in an SDoH screening. Therefore, it can be helpful to give the patients a little “advance warning” or context about the project.

Especially for cases in which you will be screening a large proportion of admitted patients, you may want to develop a flyer or brochure (perhaps in multiple languages) that introduces the project in patient-friendly language. The flyer used by Caring Beyond Healthcare participants is shared as Example 4. It is downloadable from www.Medicare.QualisHealth.org/CBHC

In addition, you may want to develop scripts, or just a few important talking points, for hospital staff to use when:

• First approaching the patient about the screening

• Conducting the screening

• After the screening is completed - At this point, ask to put the community hub into the patient’s cell phone contacts.

This step may help the community hub be more successful with their follow up, since phone calls with a recognized caller are more likely to be picked up.

As mentioned on page 3, rely on the expertise of the community hub to recommend wording—and perhaps conduct in-person training—in order to ensure that staff are comfortable and skilled in conducting the patient interview.

Finally, it may also be useful to provide the patient with a flyer or brochure introducing the community partner and its services. Helping the patient become more familiar with the community partner increases the likelihood that they will accept their services.

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Example 4: Project Introduction for Patients

The flyer is downloadable from www.Medicare.QualisHealth.org/CBHC

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5. Conduct Pilot Testing Before launching the intervention, it is important to test all the steps. Find a couple of willing hospital staff members, identify one or two community hub staffers, and designate a short period of time for a pilot test.

If you decide to make substantial changes, perform additional tests until:

• The workflow is efficient and consistent at both the hospital and the community hub

• You are receiving consistently positive feedback from the selected patients

• You are collecting the types of data you will need to monitor the project over time

It is much easier to refine your plan before full implementation than after you have trained staff, requested EHR modifications, or made any other substantial investments in this initiative. Pilot testing gives you time to make these changes.

6. Kick Off the Project Once the pilot testing is complete, it’s time to kick off the project in earnest. Communicate with organization leadership, and be sure to conduct training with the expanded set of staff members.

The kick-off date is also a day to celebrate. While your work is not done, you have reached an important milestone. Your next milestone? Sharing results and lessons learned with other facilities! Qualis Health looks forward to hearing all about it.

Some CBHC participants found that they had been too ambitious in defining their initial population of focus and had to scale back for the pilot test to include just those members of the population who were admitted on a certain day of the week, to a certain unit.

Others found that they had defined the population based on information that staff would have a difficulty determining during the normal course of providing care (such as targeting only dually enrolled Medicare/Medicaid beneficiaries).

Another participant found that completion of the screening as part of the admission process resulted in the information being buried in a narrative that was not easy to pull back out of the EHR. Although they could temporarily collect data through chart abstraction, a different solution was needed in order to capture the data in a way that could later be pulled into a report.

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7. About the Caring Beyond Healthcare Pilot Project

In Idaho and Washington, hospitals identify and respond to patients’ social determinants of health (SDoH) needs mostly on an ad hoc basis. Qualis Health hypothesized that:

• By implementing a standardized, systematic process within a hospital admission to: - Identify Medicare beneficiaries with poor SDoH, and - Connect them to appropriate community-based social service providers

• The following results would occur: - More robust clinical-community linkages would develop - Beneficiaries’ health outcomes would improve - Medicare’s healthcare expenditures would decrease

Three Idaho and four Washington hospitals, plus the corresponding Area Agencies on Aging (AAAs), participated in the Caring Beyond Healthcare pilot project.

Findings During April 1, 2017 – April 30, 2018, nearly 1,500 patients were screened. Poor social determinants of health (SDoH) were identified in roughly half the screened patients; half of those were referred to the local AAA and nearly 60% (for a total of 230 patients) were successfully connected to community resources. Chart reviews were conducted at one hospital in order to analyze pre- and post-intervention hospital utilization. The analysis was limited to 38 patients who had been referred to their AAA. Further narrowing the focus, 22 of the patients who had been successfully connected to community supports were among those included in the chart review; this population experienced a 64% decrease in hospital admissions and a 56% decrease in ED visits (that did not lead to hospital admissions). Although the study did not attempt to determine the degree to which the decrease in hospital utilization by the successfully connected patients was due to the project or other reasons, it is a strong indicator that an impact was made at that facility.

The connection is less clear when attempting to apply the one hospital’s results to the other participating hospitals or to any other facility. Differences in populations (regarding health conditions and SDoH), as well as variation in the services accessible by specific communities, would substantially affect the results of similarly designed projects.

The varying degrees of engagement by both hospital leaders and the hospital staff tasked with conducting the screening proved to be a challenge to the project’s recruiting, planning, and implementation. Those that completed the project learned that systematic screening, referral and connection to services, while a seemingly simple process, can be valuable and effective in both rural and urban settings.