Crossroad Health Center - OTR

Amanda Ojugbeli, Summer 2018

This summer Shawn Krishnan and I worked at Crossroad Health Center (CHC) in Over-The-Rhine. Most of our time was spent screening patients for any social determinants of health (SDH) that they might face and then finding ways to connect them with community partners who could address their needs. The World Health Organization (WHO) defines social determinants of health as “conditions in which people are born, work, grow, live, and age and the wider set of forces and systems shaping the conditions of daily life” Studies have shown that medical care only accounts for 10-20% of the modifiable contributors to healthy outcomes for a population. The other 80-90% of health outcomes can be attributed to social determinants of health.

This SDH screening is part of a larger plan developed by the Center for Medicare and Medicaid Services (CMS). CMS has recognized the importance of screening for social determinants of health and has tasked healthcare providers in 31 cities to help address needs in their patient population. The goal of the project is to see if addressing social inequities in the areas of housing, food security, transportation, utilities, and interpersonal safety can help reduce medical costs via hospital utilization. Through the CMS screening, all patients with Medicare and Medicaid would be screened in the clinic. If patients have an identified need and are considered high risk (greater than 2 emergency room visits within the past 12 months), then they will be assigned a navigator to help link them with community resources. If they do not meet that criteria, then will be given information about resources in their community. Crossroad Health Center is one of the clinical delivery sites for this 5-year project, so this summer we were tasked with piloting this screening before it went live in August.

During our time at CHC this summer, Shawn and I found ways in which the screening could be optimally incorporated into the daily workflow. Additionally, we tried to find any identifiable risk factors associated with SDH. Although we didn't find that any chronic condition was linked to any SDH, we did find that patients with diabetes or obesity had a higher chance of having gone to the emergency room 2 or more times, qualifying them for a navigator. During our time at CHC, we realized that it would become an operational burden on existing staff if every Medicare and Medicaid patient were screened. To address the increased operational burden, Shawn and I suggested that only diabetic and obese patients are screened. This would reduce the overall number of patients screened, while increasing the likelihood that those screened would receive a navigator to connect them with community partners as opposed to relying on an internal referral service. Additionally, Shawn and I applied for the UC Bicentennial Community Engagement Grant, which would allow undergraduate students to administer the screenings as well as help with any internal referral process for the patients that would not qualify for a navigator. Hopefully, addressing the SDH of the patients at CHC will improve patient outcomes over the 5-year course as well as educate patients and providers on the important link between SDH and health.