Social Determinant of Health Screenings and Referrals

Patient-Centered Medical Homes (PCMHs) seek to put the needs of patients first, offering health care services that are comprehensive, coordinated, and accessible–regardless of whether the needs of their patients are simple or complex.

As part of Michigan’s State Innovation Model (SIM), the Michigan Department of Health and Human Services asked hundreds of SIM-designated PCMHs across the state to annually screen their patients for social needs including: food security, housing, financial strain, transportation, literacy, and utilities such as water, heat, and electricity. As patients reveal needs, these Patient-Centered Medical Homes provide referrals to existing services designed to help their patients.

In the Livingston/Washtenaw County Community Health Innovation Region, 54 Patient-Centered Medical Homes, which employ nearly 400 health care providers and serve more than 100,000 patients, are conducting these social determinant of health screenings. Once needs are identified, these PCMHs work to connect patients to resources to meet their needs.

Through July 2018, these Patient-Centered Medical Homes–operated by Huron Valley Physicians Association (HVPA), Integrated Health Associates (IHA), and Michigan Medicine–had screened more than 72,000 well-visit patients in Livingston and Washtenaw Counties, gathering and aggregating data about their key service needs and referring all willing patients to community organizations and services designed to help. Michigan Medicine is also screening patients for employment needs and Integrated Health Associates (IHA) is screening for child care, elder care, and social isolation.

Staff from these medical homes are now working with others to aggregate data from these social determinants of health screenings and to share them more broadly.