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Internal Medicine


INTRODUCTION: It is estimated that clinical care accounts for only 20% of health, while behaviors, physical environment, and social and economic factors determine the rest. The social determinants of health include the basic life needs of housing, food, transport, along with other factors that include employment, education, drug and alcohol use, dental and eye care, etc. Insecurity in these socioeconomic factors are expressed in chronic medical illness, mental health problems, substance use, all leading to high healthcare utilization. Healthcare costs and utilization decrease when when these needs are provided for. In a survey of 6,000 Providence patients, 50% expressed a social determinant need. Providence subsidizes Community Resource Desks around Oregon, staffed with bi-lingual resource specialists from local social service organizations, designed to connect individuals in need of support with resources available in their community. A model for referral to a local Community Resource Desk was created and patients referred to the desk to provide for any social needs.

OUTCOMES: More than 250 of our Providence St Vincent Resident Clinic patients were referred and offered resources in the 1st year of the project. At peak screening 30-40 patients were referred monthly. Most of these patients would not have otherwise come to our attention. Most common resources provided: dental care, housing/rent, utilities, food, transport, employment assistance, health insurance, English/computer classes. We are better able to care for our most vulnerable patients including non- English speakers, uninsured, and Medicaid/Medicare patients. Clinic staff and providers expressed satisfaction with the simplicity of the process.

DISCUSSION: ● This system allows for more comprehensive care, streamlines workflow for providers, and allows providers to practice in a way more in line with their goals. In addition, multiple studies show cost savings benefits to implementing similar programs. ● One study with a similar intervention noted 10% yearly health care cost reduction for those who had their social needs met. ● Vermont Health system- implemented multidisciplinary team care model adding Community Health Specialist. Found tremendous cost benefits and decrease in hospital admission rates(declined 21%) and ED utilization(declined 31%). Per person per month costs fell 36%. ● We are in the process of collecting data on how this is impacting our quality metrics including healthcare utilization, hospitalization rates and per patient/per month costs.


Internal Medicine


Graduate Medical Education

Conference / Event Name

Academic Achievement Day, 2020


Providence St. Vincent, Internal Medicine Residency, Portland, Oregon

Addressing The Social Determinants of Health in the Clinic Setting