Long-term and post-acute care (LTPAC) patients have many different concerns and challenges, and it's not always easy to put the pieces together. You can have a patient who does all their physical therapy, follows their prescribed diet without complaint, and recovers before their surgeon predicted — only to end up back in the hospital before you can say "eat more vegetables."
Those rebounders often have social barriers that prevent them from follow-up care or complying with discharge instructions. That's why it's so important for LTPAC clinicians to incorporate a social determinants of health screening tool. These standardized questionnaires tell you about your patients' resources and support systems in the "real world" — allowing you to develop a post-care plan that's actually realistic.
If you're familiar with the patient-centered care model, you know that medicine is only part of the picture. That's particularly crucial to remember in LTPAC, where you're serving as the bridge between hospital and home. Patients with unfavorable SDOH can recover more slowly, struggle more with symptoms, and may be more likely to end up back in hospital care.
To figure out who falls in which category, you need to understand where people land in the five domains of social determinants of health:
There's a lot going on — and that's exactly why clinicians need high-quality screening tools for social determinants of health. With appropriate tools, any qualified team member can conveniently and sensitively screen for SDOH or have patients fill out questionnaires.
If patients automatically told you everything you wanted to know, your job would be a walk in the park. In the real world, standardized screening tools can help to gather the information you need.
The simplest tool is the Core 5, which asks five yes-or-no questions to evaluate food, housing, safety, transportation, and utility service needs. Other screening tools go more in-depth, asking up to 23 primary screening questions and potential follow-ups.
Collected data addresses topics such as:
Literacy and school background
Childhood and family relationships
Employment and work-related risks
Housing and food security
Social needs and challenges
Clinicians and care teams use this information to personalize care plans based on patient needs.
LTPAC providers have to juggle many different types of care like multicolored bowling pins — on fire. A social screening tool essentially puts the fire out by identifying patients' unique needs. This simplifies care management while supporting better health outcomes.
For example, say you have two patients who need a low-sodium diet after discharge. Without SDOH screening, you might not know that Patient#1 lives alone in a food desert and can't drive, while Patient #2 lives around the corner from his daughter's favorite farmer's market.
Taking SDOH into account, you can coordinate care delivery so Patient #1 has access to delivery of the right food and a ride to physical therapy. You can even share SDOH results with care partners "on the outside," so everyone on the team provides accessible and appropriate care. Care quality measures improve, and patients do better.
The next challenge is choosing the right standardized assessment. Standards are essential because you'll get the most complete and reliable information if everyone answers the same set of questions.
There are a number of options for social screening tools, so be prepared to do some research. Know whether you plan to always have a clinician administer the test, or if you'll sometimes have patients self-administer. Think about your workflows and how well a tool will integrate with your electronic health records (EHR) system.
Your tool should have reporting capabilities and make it easy to follow up on a patient. Data collection is important, but for it to be useful, you should be able to find whatever patient info you need with just a few clicks.
Delivering top-quality care in LTPAC is like walking a tightrope over a pit of alligators, but instead of bloodthirsty reptiles, you have heavy caseloads, high staff turnover, and a budget-strained healthcare system. Add the communication challenges that come with serving high-need patients, and implementing a new tool can seem overwhelming.
Yes, you will have to train clinicians and staff on your SDOH tool, and some of them may still be getting up to speed on safe patient transfers. And you should take the time to verify with your cybersecurity expert that your tool is HIPAA complaint.
But if you have the right care coordination software and can connect SDOH data to it, all of that prep will ultimately save much more time than you spend on setup, while making for a better experience for staff and patients alike.
The best care coordination systems put you and your patients front and center. ChartPath's EHR software targets the unique needs of LTPAC organizations and their complex patients with seamless CDOH integration, including easy-to-use reporting and decision support functions.
We make it easy for you to gather and analyze the patient data you need. With ChartPath, you can spend fewer hours updating home care aides on patient needs and more time actually working with the patients themselves providing care.
See how ChartPath turns charting and patient data compilation from an uphill battle to a casual stroll. Explore our EHR today.