To pilot test, evaluate, and recommend modifications to a screening, referral, and feedback process that connects patients that screen positive for one or more social needs to appropriate community-based organizations (CBOs) for social support services.
Family Health Centers at NYU Langone (FHC) is one of the largest networks of federally qualified health centers in New York City, and serves over 100,000 patients annually, from a wide array of diverse cultures. Its Flatbush Family Health Center serves a large West Indian/Caribbean population in East Flatbush, Brooklyn. The 40 staff at this location serve more than 7,800 patients a year with over 25,000 unique visits.
The work of developing a closed feedback loop process to address social needs includes refinement of an existing screening tool that is already integrated into the electronic medical record at FHC to ensure that it is culturally competent; workflow redesign for screening and referral; and development of a feedback process-model between the Flatbush clinic and CBOs. FHC will partner with the Caribbean Women’s Health Association (CWHA) and CAMBA for this project. FHC will work with CWHA and CAMBA to develop a coordinated community approach to the challenges that SDH present to the target population, and to establish a common agenda for problem solving. Anticipated agenda items will be data collection and transparency between organizations, systems communication and continued tracking, and development of referrals and patient progress.