HealtheConnections successfully completed a pilot project aimed at improving the health of low-income individuals and families by addressing Social Determinants of Health (SDoH). SDoH are conditions in the environment where people live (e.g., housing, transportation, food insecurity, health insurance) that affect health outcomes. With funding from a grant of the Mother Cabrini Health Foundation, HealtheConnections partnered with the Food Bank of Central New York, ACR Health, Seven Valleys Health Coalition, and several health care providers in Central New York to implement the project.
Healthcare providers were asked to systematically screen patients for SDoH and encouraged to use Z codes to document these social issues. Z codes are the ICD-10-CM encounter reason codes used to document SDoH data. Using HealtheConnections’ Community Referrals application, patients were referred directly to community partners to receive services to address their individual needs. The Food Bank provided services to address food insecurity, ACR health provided services to support health insurance enrollment, and Seven Valleys Health Coalition provided transportation services. Working in Cayuga, Cortland, Onondaga, and Oswego Counties, over two thousand people were reached through this initiative, exceeding our goal for the grant and providing needed services to the community. This project highlighted the roles healthcare providers and HealtheConnections can play in screening patients for SDoH, compiling SDoH data, and referring patients to our community partners.