ACS SDOH Health System Assessment Tool
The matrix below will help you identify next steps to expand your capacity for screening patients for social determinants of health. Based on your answers to the assessment, below are 'next steps' within each category. Any categories where you reported a '4' are deemed to be strong and do not require next steps. Review how you answered on the ACS SDOH Health System Assessment and identify the appropriate next steps.
Key: The matrix below organizes the assessment categories into three tiers. Each of the tiers and corresponding categories are detailed below:
Tier 1: Fundamental components - leadership, system prioritization, and champions.
Tier 2: Implementation resources - staffing, reimbursing staff time, SDOH screening topics and tools, and goal setting & measuring.
Tier 3: Systems Integration - workflows, EHR integration, and tracking & monitoring patients screened for SDOH.
Form Submitted By
Recommendations: Tier 1 - Fundamental Components
Answer1
System Leadership
1. The commitment of leadership in this health system to address SDOH...
- Meet with health system and clinical leadership to explore their interest and willingness to support SDOH.
- Meet with health system and clinical leadership to explore making SDOH a particular focus or topic area.
- Congratulations, you are working at an optimal level in this area.
Answer2
System
Prioritization
2. Screening and addressing SDOH...
- Determine whether leaders, clinicians, and clinical staff think SDOH screening and linkage to services is important for clinical care.
- Determine whether leaders, clinicians, and clinical staff believe SDOH should be prioritized by the organization.
- Determine whether the current level of prioritization of SDOH is sufficient to effectively screen and link patients to services.
- Congratulations, you are working at an optimal level in this area.
Answer3
Champions
3. Responsibilities for supporting and implementing SDOH screening...
- Identify a potential clinical champion for the SDOH screening and linkage program.
- Use the Clinical Champion Checklist on page 18 for considerations in selecting a champion.
- Work with leadership to identify resources to provide champion protected time, EHR staffing support, or other project management support for the program.
- Congratulations, you are working at an optimal level in this area.
Recommendations: Tier 2 - Implementation Resources
Answer1
Staffing
4. Staffing to support SDOH screening and referral, such as case managers or patient navigators...
- Discuss staffing support opportunities (i.e. roles, responsibilities) with your health system and clinical leadership.
- See the Reimbursing Staff Time for SDOH Screening and Linkage on page 19.
- Congratulations, you are working at an optimal level in this area.
Answer2
Reimbursing Staff
Time
5. The ability to reimburse staff time for screening for SDOH and supporting linkages to services...
- Explore the ability to reimburse for services through Medicaid.
- See the Reimbursing Staff Time for SDOH Screening and Linkage on page 19.
- Congratulations, you are working at an optimal level in this area.
Answer2
SDOH Screening - Topics
and Tools
6. The health system...
- Use the Screening and Community Resource Referral Checklist on page 20 to explore what SDOH components to screen for and what services exist for linkages.
- Identify what services need to be expanded.
- Conduct ongoing outreach to community agencies to expand services.
- Congratulations, you are working at an optimal level in this area.
Answer3
Goal Setting and
Measuring
7. Goals for SDOH screening and linkage to services...
- Use the SMART Goal Setting & Measurement on page 23 to identify goals and metrics to track progress.
- Congratulations, you are working at an optimal level in this area.
Recommendations: Tier 3 - Systems Integration
Answer2
Workflows
8. Clinic workflows for screening patients for SDOH...
- Use the Workflow Process Map on page 25 to develop a workflow for screening and linking patients to SDOH services.
- Use the Workflow Process Map on page 25 to map the existing workflow for screening and linking patients to SDOH services, identify challenges, and explore potential solutions.
- Congratulations, you are working at an optimal level in this area.
Answer2
EHR Integration
9. SDOH screening tools...
- Meet with IT/EHR staff to explore whether the current EHR allows for screening for SDOH.
- For more information, review Integrating SDOH Screening into the EHR on page 27.
- Meet with IT/EHR staff to explore whether the current EHR allows for screening for SDOH.
- For more information, review Integrating SDOH Screening into the EHR on page 27.
- Meet with leadership to identify resources to expand IT support for building systems.
- Use the Workflow Process Map on page 25 to map how the screening tool is entered into the EHR, identify challenges, and explore potential solutions.
- Congratulations, you are working at an optimal level in this area.
Answer3
Tracking and Monitoring
Patients Screened for SDOH
10. The use of a system to track and monitor patients screened for SDOH...
- Meet with IT/EHR staff to explore whether the current EHR allows tracking or monitoring screening.
- For more information, review Integrating SDOH Screening into the EHR on page 27.
- Meet with IT/EHR staff to explore whether the current EHR allows tracking or monitoring screening.
- Meet with leadership to identify resources to expand IT support for building systems.
- Congratulations, you are working at an optimal level in this area.
The assessment tool will assist health systems to assess their current practices and capacity to screen patients for social determinants of health (see: Screening for Social Determinants of Health Guide).