West Health is advancing innovative ways to better screen for and address modifiable social risk factors that impact healthcare costs and influence health outcomes by advancing the connection and coordination across healthcare and community settings, ensuring the delivery of whole-person support.
Social determinants of health impact healthcare costs and health outcomes. As such, there is an opportunity for healthcare settings to partner with community-based organizations to address modifiable social risk factors, including unmet social needs of their senior patients and clients.
The West Health Institute, in collaboration with the University of California, Irvine (UCI) and SeniorServ, a community-based organization, advanced whole-person support within an established senior health center by embedding a care navigator within the clinical care team; developing and testing a senior-specific screening tool to identify modifiable social risk factors; and utilizing a technology platform to link patients to community-based support services.
The primary aim of this study was to transform the patient experience from disjointed healthcare and community services to a comprehensive care plan that considered all the needs of a senior, coordinated their care across settings and providers, and altered their care plan based on current and changing needs.
As part of a multi-year collaborative research project, we are instituting and testing a technology-enabled care coordination model of care, focused on social determinants of health, that identifies and addresses modifiable social risk factors and bridges healthcare and community settings to deliver whole-person support for seniors.
A Practical Guide to Addressing the Social Needs of Older Adults details how to implement a social needs screening and referral program for older patients into clinical practice. Driven by significant growth of the older adult population across the United States and the demand to improve health outcomes and reduce healthcare costs, there is heightened attention and increased awareness of the importance of social determinants of health.