Crossroad Health Center - OTR

Kati Woodward, Summer 2019

Crossroad Health Center is one of several clinics in Cincinnati participating in the Center for Medicare and Medicaid Services (CMS) Accountable Health Communities Model. The goal of this model is to screen Medicare/Medicaid beneficiaries for SDH, provide neighborhood resources for those that screen positive, and connect “high risk” patients with community partners that will help them navigate resources to address their needs. My main responsibility this summer at Crossroad was to perform the SDH screening with patients when they were at the clinic for regular visits with their provider.

From the very beginning, it became clear that the prevalence of SDH was high and the ability to address the needs of patients was lacking. Through the Accountable Health Communities Model, only patients with Medicaid or Medicare and 2 or more ER visits were eligible for navigation, which ended up being a very small percentage of all of the patients that were screened. At Crossroad, we screened all patients regardless of if they had Medicaid/Medicare or not. Since most patients we screened were positive for at least one need and likely wouldn't qualify for navigation through the CMS project, there was a need for something to be in place to address the identified SDH of these patients. During the first few weeks, Alex and I worked to create a pamphlet of resources in the neighborhood. It is currently in the process of being published and it will soon be available at all Crossroad sites for patients to access.

The screening questions included some pretty personal questions, asking about food security, reliable transportation, interpersonal violence, and housing issues. It was striking to me how open and honest patients were with me as I was asking these questions. Several times, patients actually thanked me for asking them because it is something that they have never been asked before in their doctor's office. There were also a few patients that at the time of me screening them, they were experiencing a social determinant of health for the first time, and using the resource pamphlet that Alex and I made, I was able to connect them with resources that they wouldn't have known about otherwise. Being able to spend my summer meeting with patients and having conversations about ways to address their SDH was so eye opening and such a good experience for me. I know that I will take this experience into my future career and it will make me a better physician in the long run. To be a physician is to care for every aspect of a person and to advocate for them whenever possible, which is something that I understand so much more now because of my summer experience at Crossroad.

Download Alexander & Kati's poster (.pptx)