A Comparison of Social Referral Network Utilization Across Different Residency Clinics: A Quality Improvement Project

From the 2023 HVPA National Conference

Elizabeth Mikhail MD (Mclaren Healthcare), Tejaswi Vinjam MD, Aaron Kurian MD, Carlos Rios-Bedoya M.P.H., Sc.D., Rebecca Pratiti MD

The impact of social determinants of health (SDOH) on individuals’ health and quality of life is well-established. One approach for addressing SDOH is through a “Social Referral” (SR) model, which links healthcare services with community resources via shared electronic or organizational platforms. Success of these linkages is heavily influenced by the referral methodology used. Limited data exist on SR rates for residency program clinics, and rates vary depending on clinic location and patient age. The Community Health Access Program (CHAP) is a collaborative, community-based medical home improvement model to improve patient access to community resources for addressing SDOH. CHAP is being used by the internal medicine residency clinic (IMRC), family medicine residency clinic (FMRC), and County Free Medical Clinic with residents (CFMC) to make SR. This SR process varies in each clinic.

The effectiveness of CHAP referral processes and rates were evaluated for IMRC, FMRC, and CFMC. CHAP SDOH questionnaire is set at 5th-grade reading level and takes 5-10 minutes to fill out. It is administered to patients if SDOH affecting patient health is noted by clinic staff. CHAP referrals could be electronic only or paper-cum-electronic format. In IMRC and CFMC, CHAP referral paper form is placed in a folder and uploaded manually to CHAP system. In FMRC, CHAP referral form is created and uploaded to CHAP system electronically. We obtained information regarding number of referrals to CHAP from all three clinics (IMRC, FMRC, CFMC) from 03/01/2021 to 09/30/2021. Average referrals per month and referral rates per 1000 clinic visits were calculated for each clinic.

CHAP referrals were ongoing for the entire duration of study in IMRC and FMRC though started in CFMC on 05/2021. CHAPS referral rate was highest for CFMC 20/1000 as compared to 9/1000 for FMRC and 1.53/1000 for IMRC. FMRC had highest number of referrals (n=45). Average (±standard deviation) referrals per month for IMRC was 1.67 ± 0.94, FMRC 6.43 ± 3.2, and CFMC 2.5 ± 0.5. Chi-square statistics were significant (p-value <0.00001). Two-sample test of proportion for FMRC vs. CFMC was not significant [Confidence interval (CI) -0.028, 0.007] and significant for FMRC vs. IMRC [CI 0.005,0.011] and IMRC vs. CFMC [CI -0.036, -0.001].

SR rates increase with referrals completed electronically as seen in FMRC. Residency clinics with pediatric patients and uninsured patients have higher SR. CFMC external CHAP referrals could have been affected by addressing some SDOH within clinic’s point-of-care resources (free bus passes, pharmacy). Residency clinics lag in SR rates. Our study rates are significantly lower than referral rates from previous studies ranging from 62-155/1000. This denominator varies in studies since some only include number of participants screened and others total number of patient visits, making comparisons difficult. Previous pediatric residents’ study suggested time constraints as a barrier for SR, therefore utilizing an online SR process has higher likelihood of referral by decreasing time constraints on residents.

Clinical Implication:
An online SR system like CHAPS allows providers across different practices and regions to efficiently refer patients for SDOH. Furthermore, one-question SDOH screening routinely for all patients (like PHQ-2), followed by a full SDOH questionnaire for those screening positive, may improve clinic workflow and SR efficiency. CFMC transitioned to FMRC based CHAPS referral process. Residency programs should focus on awareness and interventions for SDOH amongst residents.


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