Dimock Center's SDOH Resourcing Model - Connecting Patients to Resources
Discover how The Dimock Center in Boston utilizes resource specialists to connect patients to social determinants of health resources. Learn about the model, the role of resource specialists, and the workflow involved in this innovative approach to addressing patients' needs effectively.
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SDOH in Primary Care HOLLY J. OH, MD CHIEF MEDICAL OFFICER THE DIMOCK CENTER OCTOBER 16, 2019
The Dimock Center Federally Qualified Health Center, single site campus in an urban setting in Boston, serving 19,000 patients a year Health Services primary care and integrated BH, women s health, eye, dental, pharmacy, PT, team based care Behavioral Health/Addictions detox, recovery homes, homes for patients with developmental disabilities Early Childhood Education Early Intervention, Early Head Start, Head Start Medicaid about 70%, Uninsured 10%, the balance Medicare and Commercial
What is Dimocks SDOH resourcing model? Resource specialists/CHWs embedded within departments Patients can be connected through screening in primary care, or patients can request to meet directly with RSs (especially if they have used the service before) Resource Specialists are supported by software They are responsible for connecting patients to resources to serve the identified needs
Who are our resource specialists? Embedded within Adult Medicine, Pediatrics, Ob-GYN, and complex care management High school grads, Associate s degree, Bachelor s degree Ideally, linguistic/cultural capabilities Good communication and customer service skills; organization and follow through; teamwork; computer skills One model- hired by Dimock; another model one Dimock employee coordinates volunteers from area colleges NOT social workers
How does the work flow? Need identified (universal screening, patient identified, staff identified) Staff hands off patient to resource specialist (RS) in person, or virtually through EHR referral, or patient self-refers RS meets with patient, reviews need, details and specifics Uses software to help search for resources, as well as to log in the interaction for tracking The connection can be a Rapid Resource Referral (provide info) or full connection to resources Follow-up with patient did they go?
Software to support SDOH connection Find SDOH resources o Crowdsourcing Yelp type search capabilities o Provide connection information from software Tracking connections through to completion o A reminder did that patient get connected? o Capability to text Reporting capability Ideally, integrated to EHR
Why is this important in primary care? Social resource needs are a significant driver in health and wellness If social resource needs are ignored, they can be a barrier to achieving health Resource specialist is a key part of the medical home TEAM Notice it is NOT a social worker we staff with high school grads, associate s or bachelor s level folks, supported by software. This frees up our Master s level social workers to provide behavioral health therapy
