Caring for patients beyond the health care setting

Health care continues to change for the better, with technological advancements and the use of big data. However, the way care is delivered mostly remains the same. You come in with a broken bone; you are treated and leave. You come in for food poisoning; you are treated and leave. You come in with a lack of energy; you are treated and leave.

Clinicians typically deal with the diagnosis or disease process but don’t get to the bottom of why these issues are occurring. Maybe the person with the broken bone is in an abusive relationship. Maybe the person with food poisoning only had access to spoiled food. Maybe the person with no energy doesn’t have the money for healthy fruits and vegetables.

“As a Registered Nurse, I, and my fellow Mission Partners have seen it all,” said Vicki Trainor, coordinator of Performance Improvement and Education for OSF Medical Group. “In many cases, we’ve pulled out our Rolodex to connect patients with social services that could help. However, we haven’t had a good way to tie people to the non-clinical support they need.”

This is especially the case in rural areas where many individuals have to travel 20 to 40 miles to get to crucial services, including the hospital. An OSF team in a non-urban area has worked diligently with OSF Innovation to create a new normal in health care – one where patients are treated beyond the health care setting.

Creating Screen and Connect

Working with Performance Improvement, the team made up of clinical and non-clinical staff came up with a process to easily identify people in need of social services and connect them to helpful resources. With input from front-line staff and five months of building, they came up with Screen and Connect.

Screen and Connect is a digital tool that evaluates patients for various social needs. This includes food insecurity, financial support, transportation and partner violence. As individuals come in for appointments, they are asked to fill out a 12 question survey on a tablet. The questionnaire asks about the non-clinical issues patients face and whether they want assistance.

“That information is automatically populated into the patient’s medical record,” said Trainor. “If a patient is flagged as at risk, we can talk to them about their challenges, offer support and refer them to a care manager for additional assistance. The patient will walk out the door with the information they need to keep themselves healthy.”

Dr. Sarah de Ramirez is the vice president and chief medical officer for OSF Innovation. She oversaw the development and implementation of Screen and Connect. Dr. de Ramirez says the eventual goal is to create a two-way communication tool between OSF and community-based organizations.

“This would allow us to refer patients to social service agencies—much like a doctor or advance practice provider refers a patient to a specialist for a specific type of care,” said Dr. de Ramirez. “Our health care teams and community-based organizations could then easily refer people to each other, follow up on progress and track that work over time. We would also have the information we need to identify the types of organizations that should exist to better serve our patients.”

Nine rural clinics are using Screen and Connect on a daily basis. However, similar solutions are in the works for the urban areas OSF serves.

Making a difference

Trainor says she will always remember the first time she realized how transformative using Screen and Connect could be.

“We had a young person come to one of our facilities seeking care. The survey found the patient to be at high risk for homelessness. They didn’t have access to healthy food and endured financial strain.  The patient also shared that they were in an abusive relationship,” said Trainor.

This led to a conversation about how OSF could help them get out of their situation. While they did not accept this assistance, they DID ask for help with housing, food and paying bills. Their goal was to regain their independence and move away from their significant other.

“This young person was thankful, teary-eyed and hopeful for the future, saying, ‘I can’t believe you guys are even asking me these things. I’ve had these issues for so long and never knew where to go or that anybody even cared,’ said Trainor.

“This reminds us of why we do what we do. Using Screen and Connect gives us, as caregivers, the opportunity to better care for the whole person. We will also know that they are getting more than medical treatment. They are receiving the greatest care and love that OSF HealthCare is known for.”

Last Updated: January 26, 2021

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About Author: Denise Molina-Weiger

Denise Molina-Weiger is a Writing Coordinator for OSF HealthCare, where she has worked since March 2015. She initially came to OSF to write about the work taking place at the Jump Trading Simulation & Education Center, one of the world’s largest simulation and innovation centers and went on to become the Media Relations Coordinator for OSF Innovation which was developed to help the hospital system lead the way in transforming care.

Before joining the OSF HealthCare team, Denise was a reporter for Peoria Public Radio for ten years, writing on everything from politics, housing and transportation issues to hospital care in the region. She earned her bachelor’s degree in radio broadcasting from Western Illinois University in 2003 and received her master’s degree in public affairs reporting from the University of Illinois at Springfield in 2004.

Denise lives in West Peoria with her husband, son and two crazy dogs. In her spare time, she likes to snuggle on the couch with her family and watch cooking shows on Netflix. She loves taking road trips with her family and then complaining about it when they are over.

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Categories: Innovation