Prior or after the initial appointment, at discharge, and on every home visit) and part of nursing orientation processes.
Prior or after the initial appointment, at discharge, and on every home visit) and part of nursing orientation processes. The frequency of SDOl-l screening must be clearly outlined, noting that it may be adjusted ac— cording to the patient’s risk level and ongoing needs. As SDOH data are modified over time, the creation of an electronic notification within the EHR would be beneficial to alert care team members when new data are present. Procedures for successful screening should consider patient education on the reasons for collects ing data, how it will be used, and who will have access to the data. Access to and integration of SDOH data Using collected SDOH data, nurses will have the ability to identify patients at risk for negative health outcomes and connect patients with needed services. Based on the socior economic and environmental needs and risks ofthe patient, SDOH data can be reviewed regularly along— side the plan of care to address the patients needs. Easy access to and visibility of SDOH data facilitates referrals to community services and supports a greater understanding of the factors that affect health. Information overload has been a critical issue for clinicians, who often have limited time to review the vast amount of data that has not been translated into relevant informa— tion when they are needed.32 The collection and documentation of the information itself also increases responsibility and workload of nurses, who are often tasked with administrative burdens that would otherwise be outside of their job de— scriptions.3″-2" Accessing information at the proper point in the clinical decision—making process is critical? To optimize its use, SDOl-l data must be integrated into clinical workflows in a way that supports the efficient use of the information without creat— www.Nursing2022.com ing an undue burden on nurses. Common approaches to imple— menting clinical decision support tools, such as identifying the needs of the users and what the system is expected to do, may be useful in inte— grating SDOH data into workflows.:f’ This includes the use of the El-IR in presenting the right data in the right place to the right clinician at the cor— rect point of the clinical workflowd’l A thorough understanding of SDOI-l information needs in settings and situations may also contribute to its optimal integration into workflows. To decrease the cognitive burden of nurses, machine learning algoe rithms can be used to build SDOI-l data models. These types of predice tive and prescriptive analytics can provide new insights into the interacr tion between social conditions and health outcomes in specific patient populations. A recent study in the American join ml of Managed (Lure found that applied machine learning can be used to predict patient utilizar tion of inpatient and EDs based on their SDOH.” These findings can be applied on a wider scale and could positively impact patients, the com— munity; and the health systems.” Interoperability Nurses must also explore the level of interoperability or the amount of SDOl-l data exchange between healthcare organizations and external stakeholders, particularly its impact on nursing workflows. it is important that SDOI-l data can be shared and ex changed with community partners and other healthcare systems to develop a system of holistic and longitudinal care for patients, primary care providers, case managers, and other healthcare workers who may require access to SDOI—l data. Data flows should be examined, and where possible, SDOl-l data should be reused and shared for optimal use (see SDOH screening in clinical practice: Use cases)” SDOH screening in clinical practice: Use cases Use case #1: Primary care cllnlc care setting Prisma Health in Greenville, S.C., implemented SDDH screening tools in a phased approach for their value-based contract patients and uninsured patients in the primary care dinics. During the intake process, nurse care managers con- duct a basic needs SDDH screening in the EHR Next, the nurse care manager generates a list of personalized referrals via a referral platform embedded in the EHR. The referral list is attached to the After Visit Summary and shared with the patient in their preferred modality (text, email, or print). Prisma Health plans to roll out this process within all ambulatory clinics across their enterprise to screen all patients in support of their health for SDDH impact. Use case #2: Primary care and Inpatient care settings Allina Health, based in Minneapolis, Minn, utilizes the Accountable Health Com- munities (AHC) Model. During the intake process in the primary care dinics, all patients with Medicare and Medicaid are screened using the AHC screening tool. With the standardization of this process, Allina Health has been able to read1 90% of its target population screening goal along with community referrals. Patients with identified established needs receive a consult for nurse navigation. Allina Health has found that patients with existing primary care are most interested in accept- ing navigation services, highlighting the importance of establishing a primary care relationship that enables trust for the provision of senrices such as care navigation. Allina Health also utilizes the AHC screening tool in the inpatient units, focusing on the behavioral health and population of mothers and babies. Incorporating the tool into their workflow, nurses screen, identify, and "e—prescribe" personal- ized referrals based on SDOH needs and available community senrices. April I Nursingzun | 35 Coovrioht © 2022 Wolters Kluwer Health. Inc. All riohts reserved.
16. National Committee on Quality Assurance. Social 22. Collins R. Clinician cognitive overload and 29. Cantor MN, Thorpe L. Integrating data on determinants of health resource guide. 2020. www its implications for nurse leaders. Nurse Leader. social determinants of health into electronic health ncqa.org/wp-content/uploads/2020/10/20201009_ 2020;18(1):44-47. records. Health Aff (Millwood). 2018;37(4):585-590. SDOH-Resource_Guide.pdf. 23. Khademi M, Mohammadi E, Vanaki Z. 30. Olshansky EF. Social determinants of health: 17. Andermann A. Screening for social Resources-tasks imbalance: Experiences of nurses the role of nursing. Am J Nurs. 2017;117(12):11 determinants of health in clinical care: moving from factors influencing workload to increase. from the margins to the mainstream. Public Health Iran J Nurs Midwifery Res. 2015;20(4):476-483. 31. Health Level Seven. Gravity Project. 2021. Rev. 2018;39:19. doi:10.1186/s40985-018-0094-7. www.hl7.org/gravity. doi:10.4103/1735-9066.160994 18. Sprague S, Slobogean GP, Spurr H, et al. 24. Tine Health. How Patient Engagement A scoping review of intimate partner violence Tools Can Reduce Nurse Workload. 2018. Victoria Tiase is the director of Informatics Strategy screening programs for health care professionals. Accessed March 4, 2022 from https://tinehealth. at New York-Presbyterian Hospital. Cathryn DeGraff PLoS One. 2016;11(12). doi: 10.1371/journal. Crookston is the senior director for Provider Sales pone.0168502. com/2018/03/28/how-patient-engagement-tools- can-reduce-nurse-workload/ Solutions at Unite Us. Anna Schoenbaum is the 19. Fraze TK, Brewster AL, Lewis VA, Beidler LB. vice-president of Information Services Applications 25. Clarke MA, Belden JL, Koopman RJ, et al. at Penn Medicine and a faculty at the University of Murray GF, Colla CH. Prevalence of screening for Information needs and information-seeking Maryland School of Nursing. Madelynn Valu is the food insecurity, housing instability, utility needs, behaviour analysis of primary care physicians senior manager of Public Health at Circula Health. transportation needs, and interpersonal violence by US physician practices and hospitals. JAMA and nurses: a literature review. Health Info Libr J. All authors are members of the Healthcare Infor- mation and Management Systems Society’s Social 2013;30(3):178-190. doi:10.1111/hir.12036. Netw Open. 2019;2(9):e1911514. doi:10.1001/ Determinants of Health Task Force, with Ms. DeGraff jamanetworkopen.2019.11514. 26. Agency for Healthcare Research and Quality Crookston as a co-chair. 20. ANA Enterprise. Amid a Persistent Pandemic (AHRQ). Clinical Decision Support. 2019. Access Copyright @ 2022 The Author. Published by Wolters and Long Standing Staffing Crisis, Americans Rank February 14, 2022 from https://www.ahrq.gov/cpi/ Kluwer Health, Inc. This is an open access article Nurses the Most Honest and Ethical Professionals about/otherwebsites/clinical-decision-support/ distributed under the terms of the Creative Commons Attribution Non Commercial-No Derivatives Licens January 12, 2022. Accessed February 14, 2022 index.html 4.0 (CCBY-NC-ND), where it is permissible to down- from https://www.nursingworld.org/news/ 27. Osheroff J, Teich J, Levick D, et al. Improving Out- load and share the work provided it is properly cited news-releases/2021/amid-a-persistent-pandemic- comes with Clinical Decision Support: An Implementer’s The work cannot be changed in any way or used and-longstanding-staffing-crisis-americans-rank- Guide. HIMSS Publishing, Chicago, IL; 2012. commercially without permission from the journal. nurses-the-most-honest-and-ethical-professionals/ 28. Chen S, Bergman D, Miller K, Kavanagh A, 21. Phillips J, Richard A, Mayer KM, Shilkaitis Frownfelter J, Showalter J. Using applied machine M, Fogg LF, Vondracek H. Integrating the social learning to predict healthcare utilization based The authors have disclosed no financial relationships related to this article. determinants of health into nursing practice: nurses’ on socioeconomic determinants of care. Am J perspectives. J Nurs Scholarsh. 2020;52(5):497-505. Manag Care. 2020;26(1):26-31. doi:10.37765/ doi:10.1111/jnu.12584. ajmc.2020.42142. DOI-10.1097/01.NURSE.0000823284.16666.96 www.Nursing2022.com April | Nursing2022 | 37
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