Challenges

NYC Health + Hospitals is deeply committed to screening for and supporting patients with SDoH needs, and believes that a positive screen should always be accompanied by a resource connection. Each year, the health system screens more than 300,000 patients in Epic, and nearly 1 in 3 of these screened patients (34%) have at least one active SDoH need, resulting in a consistently high demand for resources.

• Meeting Requirements: In support of expanding Joint Commission and CMS regulatory requirements to screen patients in a variety of care settings, the health system needed a way to ensure that all patients in need received recommended resources.

• Automated Recommendations: NYC Health + Hospitals needed an efficient and automated way to ensure patients who screen positive for SDOH needs receive, at minimum, a list of resources to help address their needs.

• Digital Referrals: Navigators needed a quick and easy way to digitally refer patients to trusted city-based resources, at scale.

• Self-Navigation: The health system needed a community-facing resource directory to empower patients to independently search for and identify resources.

How Findhelp Supports NYC Health + Hospitals

NYC Health + Hospitals knew that in order to sustainably assist patients with social needs at scale, they needed a comprehensive solution to meet these challenges. In 2023, the health system switched from NowPow to using Findhelp as their social care platform and technology solution. To meet the unique needs and high volume of their patient population, Findhelp worked with the organization to develop and deploy two new Epic integrations that greatly automated the process of recommending and referring programs for patients: Automated Program Recommendations and Assessment-Informed Launch.

“I just used Findhelp for a patient who recently came home from 7 years in prison and now is struggling to find employment. The referral suggestions were all appropriately tailored to his needs and specific circumstances. The interface was smooth and userfriendly, and it was easy to incorporate its use into my visit. Really excited about this development. Thank you for all your hard work!”

Navigator on Day 1 of Findhelp Go-Live, NYC Health + Hospitals

Supporting Screened Patients with Automated Program Recommendations

The Automated Program Recommendations integration automatically and bilaterally ingests recommended programs into the patient’s chart and After Visit Summary® in Epic, in both English and the patient’s preferred language.

This is made possible by mapping the domains in NYC Health + Hospitals’ SDoH assessment questions in Epic with recommended resources in Findhelp. The Automated Program Recommendations integration ensures that each of the health system’s 100,000+ patients with at least one positive SDoH need are provided with a curated, recommended list of resources. By mapping SDoH assessment questions to Findhelp resources and automatically filtering based on patient location, this tool provides a streamlined workflow that requires no additional clicks or effort on the part of NYC Health + Hospitals navigators. Because these program recommendations are stored in the patient’s chart in real time, both the patient and navigator can initiate social care connections during or after the visit.

Supporting Efficient Navigation with Assessment-Informed Launch

Assessment-Informed Launch automatically ingests Epic SDoH assessment questions and creates a pre-curated list of recommended resources for navigators to electronically refer to. Where the Automated Program Recommendations integration enables programs to be pulled into an After Visit Summary, Assessment-Informed Launch complements and deepens this work by enabling navigators to more easily electronically refer patients to resources based on their SDoH assessment needs. Approximately 10% of all NYC Health + Hospitals patients that screened positive for an SDoH need had a navigator launch to Findhelp to search and refer on their behalf, facilitating connections and discrete tracking of patient outcomes. 

Results, Return on Investment, and Future Plans

To engage local community-based organizations (CBOs) in the social care referral process, NYC Health + Hospitals worked with Findhelp to establish a Trusted Network of CBO partners. They used existing relationships to prioritize specific organizations, provide specialized training, and feature them in their Findhelp platform’s search results. This strong, tight-knit network of priority partners has created positive outcomes for patients.

"As doctors, we know that too often our patients are struggling with making ends meet, and that is a particularly frustrating barrier to getting or staying healthy. This new referral platform and patient-facing website for staff is powerful new tool in our toolbox to help our patients connect with community services and resources."

Nichola Davis, MD, MS
Vice President and Chief Population Health Officer,
NYC Health + Hospitals

By aligning community engagement efforts with streamlined navigator workflows through integrations like Assessment- Informed Launch, NYC Health + Hospitals social workers and care navigators referred thousands of patients to trusted resources, resulting in a 99% referral response rate and 86% closed-loop rate.

	108K Completed SDoH assessments		3,450 Referrals made to Trusted Network CBOs
	99% Trusted Network referral response rate		86% Trusted Network closed-loop rate
Data represents Jan 1 to June 30, 2024

The implementation of efficient, tailored workflows also led to staff engagement and support for the platform, as part of NYC Health + Hospitals’ larger health equity strategy.