By David Raths at Healthcare Innovation

Provider organizations ranging from free clinics to rural hospitals are experimenting with tools and services that help them connect patients with community services such as housing, transportation and food pantries. Although closing the referral loop can be challenging, anecdotally some facilities say the screening process and follow-up seem to be having an impact on readmissions and outcomes.

Nonprofit community hospital McLaren Port Huron in Michigan has incorporated patient screenings and technology from a company called Wellopp as part of a larger readmission reduction strategy.  Holly Gould, clinical outcomes coordinator at McLaren, says the hospital initially partnered with Wellopp in March 2018 to deliver social determinants screenings to inpatients with chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). These screenings included disease-specific education, questions, and information in addition to the standard SDOH content.  Patients who take the screening receive regular text messages with medication reminders and wellness tips for up to 30 days after discharge. Patients receive a $10 gift card for filling out the initial screening and earn a total of $25 in gift cards if they follow the 30-day program through by answering all the text messages.

Gould said they customized the survey with disease-specific questions as well as the SDOH questions. One of the first text messages patients are asked is if they have seen a provider since they have been discharged or if they have an appointment. “For heart failure we would ask if they are monitoring their symptoms and weighing themselves. We would ask them if they felt they would have housing issues in the next year or trouble paying their utilities or whether they have enough money for food,” she said.  “We thought those were some reasons patients could be readmitted. We also asked whether they could not make it to follow-up appointments because of transportation issues.”

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