On November 1, 2018 Frisbie Memorial Hospital’s White Mountain Medical Center, located in Sanbornville, NH, launched a grant-funded pilot project that incorporates into the primary care setting a systems-level, data-driven approach aimed at reducing preventable ER utilization and improve health outcomes by assessing patients’ social and economic needs, or social determinants of health (SDoH), such as lack of transportation, financial hardship, food insecurity, lack of insurance, access to care, social isolation, behavioral health issues, and housing instability.

"This will be the first time we incorporate a practice-level intervention that aims to improve care coordination among healthcare providers and community resources to better meet the needs of patients and to optimize health outcomes," said Dr. Deborah Harrigan, Medical Director for Frisbie Memorial Hospital’s Physician Practice Services. The SDoH screening tool, Caring for your Health, HCDI, is designed to help providers better understand the whole patient and guide and inform care planning for at-risk patients. To assess patients’ SDoH, each patient is given a brief questionnaire to complete in the waiting area. The questionnaire responses are then entered into the patient’s electronic health record (EHR), which may prompt a referral to 2-1-1 and/or to a Frisbie Financial Counselor.

Over 600 patients at White Mountain Medical Center have completed the SDoH screening tool. Preliminary results indicate 20% have experienced food insecurity in the past 12 months, and nearly 20% report financial hardship as a reason for not going to the doctor and for skipping medications. In addition to economic risk factors, over 20% report feeling lonely “sometimes” or “often.” Unmet psychosocial needs, such as limited family support or social isolation, can increase patients’ risk for behavioral health issues.

The project is supported by the Centers for Medicare and Medicaid Services’ (CMS) Transforming Clinical Practice Initiative (TCPI), with Frisbie Memorial Hospital receiving technical assistance from HealthCare Dynamics International (HCDI), a CMS-designated Support and Alignment Network (SAN), and the Northern New England Practice Transformation Network (PTN), a project of the NH Citizens Health Initiative and New Hampshire Institute for Health Policy and Practice, in collaboration with Maine Quality Counts. “Providing a customized tool with validated questions focused on capturing real-time data is a major step toward improved population health. The importance of strong medical leadership in such efforts cannot be understated,” said Jean Drummond, President of HealthCare Dynamics International.

Get more information about HCDI.