The COVID-19 pandemic has changed our lives in every possible way in a short amount of time. While the spread of COVID-19 and the economic effects of shelter in place have impacted everyone to varying degrees across California, the gaping social disparities underscored by the pandemic make clear that addressing social needs that impact health is more important than ever. What changes are health care providers seeing and how is the role of health care evolving in this context? Here are some highlights from a recent (virtual) conversation among California Improvement Network (CIN) partners who are navigating how best to serve their patients during the pandemic:

Effective screening is foundational to supporting patients.

Robust screening and assessment tools to identify and address the specific social needs of individuals have always been the foundation of effective interventions and are particularly critical in the current pandemic. Many partners have added specific COVID-19 related screening questions to their usual work flows and others are shoring up their screening processes to strengthen them and make them even more effective. 

For example, one CIN partner shared the inclusion of a two-question screen for COVID-19 related needs in their electronic health record (EHR) system, Epic. This large health system’s ability to embed the questions in Epic means that any urgent needs identified in the screen can be automatically synced to resources through their referral platform, Unite Us.  

Another health plan partner contracted with Aunt Bertha (an online network that helps people find social services in their communities) to create a white label community resource platform. The PRAPARE assessment is embedded on the landing page for use by staff and their plan’s members.

Connecting virtually with patients is the new norm…and hard.

A key challenge most CIN partners are adapting to is how to transition to using a virtual platform for complex care management, given the important role that human connection and trust-building play in helping individuals, especially those with multiple social needs.

How can in-person visits that help individuals build trust and rapport translate to a virtual system? What are meaningful ways partners can connect with patients by video and telephone?

Another partner noted the added challenges of using telehealth with patients who do not speak English as a first language, creating additional language and technology barriers for some.

One partner, a provider support organization, has successfully built relationships and trust using telehealth by tailoring their screenings and assessments to help foster more personable interactions with clients. Patients’ medical records are reviewed in advance and screening questions are adapted to each patient’s unique circumstances. (Think, “Have you been able to follow your diabetic diet?” not “Do you have access to enough food?”) Their community health workers, who conduct the screenings, are also equipped with real time information about available resources so that they can better connect patients to needed supports.

Innovations are happening at a rapid pace. How can we capture and disseminate?

Necessity spurs innovation and many CIN partners identified the pace and scale of change in health care as one of the silver linings of this pandemic. CIN partners expressed the need to capture and disseminate these innovations and learnings and a desire to collaborate with CIN to contribute to this important work. Some of the innovations briefly mentioned include:

• Creative ways to provide essential health care services, such as drive through vaccinations for children.
• Advanced preparation for second and third waves of the COVID-19 virus by developing options to provide patients with medical devices now, such as blood pressure cuffs, and training so they can monitor their own conditions if health care access becomes significantly restricted again.
• Efforts to streamline the burden on community-based organizations to interface with multiple resource directories, and instead coordinate or have a single resource directory at a regional or county level.
• Leveraging EHR data differently to share patient data in new or different ways to more effectively support the surge in basic needs: food and housing.

The California Improvement Network (CIN) is a project of the California Health Care Foundation and managed by Healthforce Center at UCSF.

How has the COVID-19 pandemic re-shaped the way your organization is addressing social needs that impact health? What challenges is your organization facing? What questions do you have for the CIN Social Needs Affinity Group the next time they convene to discuss ideas and issues? Contact us for more information.

Additional Resources

1. Tips for providing preventive and chronic disease care during the pandemic (Department of Health Care Services)
   • Short ‘postcards’ to help health plans and providers on emerging best practices for how to prioritize and deliver essential health care services during the pandemic.
2. Resuming California’s Deferred and Preventative Health Care  (California Department of Public Health)
   • This resource includes guidance and considerations that California health care providers and organizations should review and meet prior to resuming deferred and preventative care. This guidance also encourages local or regional delivery systems to consult their local public health officers as they begin to resume services to non-emergent and non-COVID-19 patients.
3. Social Needs and COVID-19 Resource Page (SIREN-UCSF)
   • A selection of recent articles and data highlighting the impacts on vulnerable individuals and communities. Additionally, there is a link to a repository of questions developed to identify impacts of the pandemic and its aftermath on vulnerable populations.
4. Real Time 211 Data during the Pandemic (Washington University in St. Louis)
   • This online resource reports on the social impact of the COVID-19 pandemic and is powered by 2-1-1 helplines, the top surveillance system for social needs like housing, food, utility bills, transportation, child care, and health care. FOCUS-19 and 211counts.org scan the data hourly to identify rising needs in communities across the U.S.

Join Us

Stay up to date on CIN programming by subscribing to our newsletter and we’ll deliver the network’s quality improvement resources, tips, and tools to your inbox.