How Rush Incorporated SDOH into Patient Care

Nursing leaders at RUMC understood that the success of a new SDOH protocol wasn’t possible if nurses did not feel comfortable talking about SDOH with patients. So, leaders at RUMC started this work by surveying nurses across the Rush Health System about their knowledge of SDOH and comfort discussing social needs with patients.

Leaders adapted a 71-item SDOH survey that measured:

• General knowledge of the SDOH
• Frequency discussing SDOH with patients
• Familiarity with patients’ social and economic conditions
• Awareness of RUMC’s health equity strategic plan to achieve health equity

Additionally, RNs were asked to share barriers they faced incorporating the SDOH into practice. The survey took about 15 to 20 minutes, and nurses completed it at their convenience.

From August 2018 through March 2019, RUMC surveyed 768 nurses across three hospitals: RUMC, Rush Oak Park Hospital, and Rush Copley Medical Center. Facility CNOs emailed their staff and invited them to fill out the survey. To make sure they got as many responses as possible, the CNOs later sent out reminders via email.

Sample SDOH assessment survey questions

• How confident are you in your ability to discuss the following social determinants of health (social needs) with patients?
• How likely are you to ask patients about the following SDOH?
• How knowledgeable are you about the following SDOH?
• How knowledgeable are you about Rush’s community efforts in addressing SDOH?
• How knowledgeable are you about Rush’s inpatient efforts in addressing SDOH?

The survey results revealed that many of the nurses felt knowledgeable and comfortable discussing access to care, housing, and transportation issues with patients. However, nurses needed further education on other SDOH such as access to food, civic participation, crime and violence, discrimination, employment status, environmental conditions, health literacy, income, interpersonal violence, education level, social support network, and utilities.

Responses also suggested that the largest barriers to incorporating SDOH into practice included not having enough time to address identified needs and not being familiar with internal and external resources available to address social needs.

These survey results allowed nurse leaders to create a framework for educating and supporting nurses to ensure their confidence in asking patients questions about their social needs. Nurse leaders at Rush recommend that other organizations use a similar survey or focus group to get a baseline assessment of nurse skills and education and to better understand what nurses need to screen patients for SDOH. 

Nicole Wynn, DNP, RN-BC, assistant director of a postsurgical inpatient unit at RUMC, and Jennifer Grenier, DNP, RN-BC, CNML, CENP, then director of clinical operations for RUMC’s cardiac service line, used findings from the survey to design educational sessions for nurses. Together they created handouts, flyers, a PowerPoint presentation, videos, a script, and offered educational sessions to prepare nurses to screen for SDOH. one example of an education session is outlined below.

Tailored education on food insecurity

Based on data that revealed a high prevalence of food insecurity among RUMC’s ED patients, Wynn and Grenier created RUMC’s Food Is Medicine Program. The program screens RUMC patients for food insecurity upon admission. In the initial phases of the program, patients who screened positive for food insecurity were provided with food to take home upon discharge and connected with resources to continue to meet their needs.

To prepare nurses to screen for food insecurity, Wynn and Grenier created an education program on food insecurity for three pilot units. The two-part education program informed nurses of the purpose of the Food Is Medicine Program, workflow process changes, screening procedures, and how to develop SDOH conversations with patients.

Part 1: Comprehensive education

Two months before the launch of the Food Is Medicine Program, Wynn and Grenier distributed the comprehensive education material to nurses via email. The material took 15 minutes to review. Nurses could complete the education during a break period, before or after a shift, or during another convenient time. The materials included:

• PowerPoint with information about SDOH
• Brief literature review
• Information about the goal of the Food Is Medicine Program
• Map and video outlining workflow changes for the screening tool
• Script to guide nurses when screening for SDOH needs

Part 2: Demonstration sessions

During shift changes on the pilot units, Wynn and Grenier led 10-minute demonstrations on how to screen for SDOH. These sessions gave nurses hands-on experience with the functionality of the screening tool to promote their comfort and confidence.

Recommendation

Role-playing is a great way to help nurses practice key skills and translate new knowledge into practice. To get nurses comfortable screening for SDOH, consider providing a script and allow time to practice so nurses feel prepared to talk to patients about their SDOH needs. Additionally, consider organizing interdisciplinary role-playing activities that include physicians, social workers, and case managers.

To facilitate SDOH screening at RUMC, the information technology team added an eight-item screening tool to their EHR. The screening tool addresses the five main SDOH domains: food insecurity, primary care and insurance status, housing, transportation, and utilities. Information technology embedded the screening tool into the admission navigator to ensure all patients are screened. For each of the eight questions, patients may respond with “yes,” “no,” or “decline to answer.”

RUMC’s SDOH screening tool

1. Do you have a primary care physician or nurse you see regularly?
2. Do you have health insurance or a medical card?
3. Are you worried that your food will run out before you have money to buy more?
4. In the past 12 months, have you run out of food that you bought and didn’t have money to get more?
5. In the past two months, have you had difficulty paying your electric, gas, or water bill?
6. Do you have a hard time finding transportation to and from your medical appointments?
7. Do you currently have a place to stay/live?
8. In the next two months, will you have a place to stay/live?

Nurses conduct screening assessments during the patient admission process. After screening is complete, the EHR generates a report on SDOH needs. This report is visible to nursing and case management staff, so they are aware of a patient’s SDOH needs. When a patient screens positive for an SDOH need, nurses use a one-touch launch to access NowPow, a community referral platform integrated into the EHR. Using evidence-based matching algorithms, NowPow connects patients with resources within five miles of their home for any identified SDOH need.