SHM Converge Scientific Abstract ePoster Gallery-Increasing Closed-Loop Referrals for Social Determinants of Health

Pdf Summary

A multidisciplinary pediatric hospital medicine team aimed to increase closed-loop referrals for families with positive social determinants of health (SDoH) screenings from a baseline of 3% to 70% within one year. Patients were screened using the PRAPARE tool in the electronic medical record, and social workers used FindHelp to connect families with community-based resources.<br /><br />To monitor progress, the team tracked outcome, process, and balancing measures: closed-loop referrals, screening and assessment completion, length of stay, and acceptability of the process to patients/families and staff. Several PDSA cycles were implemented, including social worker education about the importance of closed-loop referrals, sharing individual referral metrics with social workers, incentivizing outside agencies to respond, and resident team check-ins during rounds with assigned social workers.<br /><br />Results showed 6,582 social work assessments completed and 2,276 PRAPARE screenings administered. Screening completion improved from 28% to 41%, and the percentage of positive screenings increased from 48% to 55%. A total of 406 families received resource referrals. After the first intervention, special cause variation was observed and sustained, with closed-loop referrals rising from 3% to 27%.<br /><br />The project demonstrated that an organized approach to promoting and tracking referrals can significantly improve closed-loop referral rates. However, the team did not yet reach its 70% target, and additional interventions are ongoing, including adding referral information to discharge summaries. Future work is needed to determine whether these referrals lead to improved social or health outcomes for patients and families.

Asset Subtitle

Ashlyn M. Jimenez

Meta Tag

Author List Ashlyn M. Jimenez, Britanny Winckler, Erika Jewell

Category Research

Concept Closed-loop Referral

Concept Social Determinants of Health

Concept Screening

Concept Referral

Concept PDSA Cycle

Distinguished Finalist

Presenter Organization University of California Irvine

Presenting Author Ashlyn M. Jimenez

Track Quality Improvement

Keywords

closed-loop referrals

pediatric hospital medicine

social determinants of health

PRAPARE screening

FindHelp

community-based resources

PDSA cycles

social work assessments

referral tracking

quality improvement

Closed-loop Referral

Social Determinants of Health

Screening

Referral

PDSA Cycle