Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:
- Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.
- Including through the use of tools that facilitate electronic communication between settings;
- Screen patients for health-harming legal needs;
- Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or
- Provide a guide to available community resources.
ObjectiveCreate formal links with community-based resources to improve patient’s health and address social determinants of health.
Evidence of availability of formal links to community-based health and wellness programs potentially including availability of resource guides that address identified social determinants of health. Include at least one of the following elements:
1) Patient social service needs screener – Copy of implemented screener (e.g., survey tool) used to assess patients' social needs (e.g., health-harming legal needs). Preferably, the screening tool is electronically enabled and includes standards-based, coded question(s)/field(s) for the capture of data as feasible; OR
2) Provision of community resource guides – Medical record demonstrating provision of a guide to community resources to meet identified social determinants of health (e.g., safe housing, transportation, social support); OR
3) Relationship with community-based chronic disease self-management programs – Documented referral relationship with community-based chronic disease self-management support programs, exercise programs, and other wellness resources (including specific names) with which your organization has formal referral links and preferably bidirectional flow of information; OR
4) Relationship with community-based organization or social service program – Documented referral relationship with community-based organizations or service programs (including specific names) with which your organization has formal referral links and preferably bidirectional flow of information.