Reprinted from the Spring 2021 Issue of The Ohio Family Physician
By: James Misak, MD; Rosemary Frech; Kevin Chagin, MS; Adam T. Perzynski, PhD; and Kristen A. Berg, PhD at the MetroHealth System Institute for H.O.P.E.TM
Experts suggest that roughly 80% of a person’s health depends on social factors beyond medical care.1 These social determinants of health (SDOH), such as unsafe housing, inaccessible healthful food and reliable transportation, education, or job opportunities drive health inequities currently magnified by the COVID-19 pandemic.
Northeast Ohio grapples with long-standing and pandemic exacerbated inequities in health and healthcare access. Despite being home to some of the best health care institutions in the world, the area exhibits deep disparity in, for instance, life expectancy2 and cardiovascular disease.3 In response, The MetroHealth System’s Institute for H.O.P.E.™ (Health through Opportunity, Partnership, and Empowerment) launched in 20194 to develop, advance, and test solutions to improve social conditions and reduce health disparities for both patients and the broader Cleveland community. Our work during the COVID-19 pandemic has focused on mitigating its social impact, and screening has been a key component in our overall strategy.
Prior to the pandemic, MetroHealth introduced a SDOH screening tool designed to better identify patients’ social needs. The tool assesses risks related to social circumstances such as inadequate housing, utilities, transportation, social connection, education, income, and digital connectivity.
Screenings are primarily completed and collected via the electronic medical record patient portal and by telephone interviews conducted by nurse care coordinators. By the close of 2020, we screened more than 32,000 individuals (see Figure 1). Leveraging this data, we developed a systematic response to the social needs of our community, the most pressing of which include food insecurity and social isolation.
Cuyahoga County is among the most food-insecure counties in the state, a severity compounded by the pandemic’s financial fallout. Social contact restrictions have stonewalled local organizations’ efforts to distribute food and many of our community members lack transportation to access basic needs while quarantined individuals are similarly homebound. In response, we configured a home delivery system in order to distribute food, personal hygiene items, and cleaning products to those unable to safely shop or travel to retrieve donated supplies. Additionally, through our participation in the U.S. Department of Agriculture’s Farmers to Families Food Box program, we distributed produce, dairy, and meat at multiple locations throughout the MetroHealth system. Leveraging partnerships with local shelters and community-based organizations, we expanded to support food and supply needs of other vulnerable community members including domestic violence survivors, unhoused individuals, and new parents. The Institute for H.O.P.E.™ team has completed 11,242 deliveries of food and other essential items since the start of the pandemic – efforts facilitated through, for instance, a longstanding and trusted relationship with the Greater Cleveland Food Bank.
As part of our efforts in tending to patients’ social needs, the Institute for H.O.P.E.™ introduced a system of follow-up phone calls to individuals screened for SDOH who demonstrated high risk for any number of unmet needs. We made over 1,200 follow-up calls linking patients to services and supports, and nearly 70% of those calls were to patients reporting extreme loneliness. While this intervention’s initial goal was to connect with older individuals socially isolated due to the acute pandemic, we find that the COVID-19 crisis has compounded loneliness and social disconnectedness for individuals of all ages. In response to these ongoing needs, we developed a phone call outreach program, Calls for HOPE, linking community volunteers with socially isolated patients for friendly conversation. Calls for HOPE provides a sustainable, inclusive way to attend to human needs for social connection and opens opportunity for conversation about other social needs-related assistance available from MetroHealth.
The pandemic has commanded critical evaluation and creative adjustment of existing social needs interventions for their long-term accessibility and inclusivity. Our food distribution and social connection efforts have been fruitful innovations in action. Community partnerships, such as ours with the Greater
Cleveland Food Bank, are critical to this ongoing work. Health care system efforts to address social needs can promote bidirectional trust and relationships with local organizations and individuals alike, relationships that will bolster our ability as family physicians and champions of health equity to alleviate patient and community social needs throughout the pandemic and beyond.
Please direct any inquiries about social needs programming to the Institute for H.O.P.E.™ by sending an email to InstituteForHOPE@metrohealth.org.
References available on the Ohio Academy of Family Physicians website.