Reading Hospital in Berks County, Pennsylvania, realized that addressing social determinants of health – conditions impacted by the places people live, learn, work and play that affect health outcomes – was a priority. It needed to be focused on really understanding the vulnerable populations in its community and to find existing barriers and address them to help get patients well and stay well.


In 2016, as just one example, the hospital started an initiative it called Street Medicine. This program focused on providing primary care to homeless or housing insecure patients where they were – shelters, soup kitchens, homeless camps and other places, said Desha Dickson, associate vice president, community wellness, at Reading Hospital. Staff started to think about screening patients for housing insecurity in the emergency department; however, the hospital did not have a mechanism to provide the screening or connect the patients to relevant resources to meet their identified health-related social needs, she explained.

“As a participant in the CMS AHC model, we received grant funding to systematically identify and address the social needs of our Medicare and Medicaid beneficiaries,” she said. “Additional analysis would prove the ROI and that SDOH interventions in fact do impact total healthcare costs and utilization.”

It is important to note that this work cannot be successful without an engaged community consortium, she added. Reading Hospital works closely with its social service partners.


For a solution to its SDOH problem, the hospital turned to Healthify, a health IT technology and services vendor that provided a way to screen patients and quickly develop a resource list. Most important, within the platform, staff could send a referral for services directly to a community organization. The closed-loop referral feature is vital, Dickson said.

“Healthify provides the means for our team to screen beneficiaries for social service needs, refer patients to social service organizations that could meet their needs, and track the outcome of those referrals,” she explained. “The vendor already had systems in place that were user-friendly, scalable and adaptable. Not to mention it could be fully integrated with our existing electronic health record and could close the loop on referrals. By closing the loop, I mean we needed a way to verify that our patient’s needs were met after providing referrals – and if not, we needed to know the reason why.”

“Data extracted from the system gives an in-depth outlook of the social needs of the patient population and the community’s capacity to address those needs.”

Desha Dickson, Reading Hospital

When staff ask patients personal questions about things like food security or housing, they needed to be prepared to offer assistance and help patients overcome these challenges in real time. Oftentimes when a patient is provided a phone number for help with their specific situation, the hospital has found that the patient actually never gets connected to those resources, or the hospital does not have the data to know if it happened or not. The new technology platform enables staff to confirm that services were provided, which enables the hospital to measure the impact of social interventions on quality indicators.

“The platform provided a streamlined process to refer patients to local resources,” Dickson said. “Its comprehensive resource classifications make it easy to search for, validate and identify resources that address social needs.”

Sometimes conflicting referral workflows can be a roadblock for many healthcare and community-based organizations working together to coordinate care for vulnerable populations. The platform’s referral management capabilities help improve operational efficiency by allowing bidirectional referrals between partners in the network, she explained.

“Clinical and community-based organizations can send and receive referrals, and track the status of those referrals throughout the care continuum,” she said. “Data extracted from the system gives an in-depth outlook of the social needs of the patient population and the community’s capacity to address those needs.”


An integration between Healthify and Epic was established to ease end-user workflows and assure data quality. Epic sends patient demographics such as name, date of birth and addresses to Healthify, where patient records are created. This allows for a more seamless approach for patient screeners who identify and screen eligible patients using the built-in social needs screening.

The vendor’s system auto-generates community resource summaries based on completed screenings and patient demographics. Patient screeners can revise these summaries as needed by searching Healthify’s resource inventory. Resource summaries are sent back to Epic through the integration to be appended to the patient’s chart.

“Community navigators utilize Epic to conduct personal interviews and devise action plans with patients who complete a high-risk screening,” said Tanieka Mason, data manager, community wellness, at Reading Hospital. “Using Healthify, they create and send referrals to community partners within Reading’s Coordinate Network on the patient’s behalf. Community partners receive, review and respond to referrals.”

“We were looking for a way to not just identify social determinants of health, but also to address them and connect our patient population to the right local sources that fit their needs at that time in their life.”

Tanieka Mason, Reading Hospital

Navigators and community partners can easily communicate and document using in-app functions regarding shared patients, referrals and service statuses, she added. Although referrals sent to community agencies out of network lack the closed-loop feature, they still are documented within Healthify and updated during ongoing follow-up with patients, she explained.

“Community partners within the network have ownership of their resource listing and can easily make real-time updates,” Mason said. “Any updates to resource listings are reported by any Healthify user and are vetted by the vendor’s resource team. Data is frequently analyzed for ongoing workflow monitoring and improvement, to identify social needs trends, and to inform the consortium’s gap analysis.”

The team at Reading Hospital uses the SDOH vendor’s data to spot social service trends among their patient population and understand referral velocity, which informs their SDOH strategies.

“Utilizing the platform, we were able to successfully screen and address patients’ social needs and share the technological capabilities with our local organizations that provide critical services in the Berks County area,” Mason said. “We now have a tool that we can use to find accurate and up-to-date community resource information and a strong coordinate network of over 20 partners such as New Journey Community Outreach, Berks Encore and Centro Hispano, just to name a few who are committed to responding to referrals.”

The system has provided a level of comfort and confidence to staff when providing patient referrals and to patients on the receiving end, she added. The CCP Consortium meets consistently to drive the intervention forward and to align on the social needs and strategies for the community, she said. The execution of closed-loop referrals and the inclusion of SDOH data within patient charts have been successfully accomplished as a result of this work, she said.

“It’s important because we were looking for a way to not just identify social determinants of health, but also to address them and connect our patient population to the right local sources that fit their needs at that time in their life,” she added.


To date, Reading Hospital has conducted more than 90,000 screenings and opened more than 4,000 navigation cases covering 36,462 Medicare and Medicaid beneficiaries. Using Healthify, approximately 9,000 community referral summaries have been generated for positively screened patients and about 6,000 referrals to community service agencies have been created for high-risk screened patients.

“We continue to expand our Reading Coordinate Network within Healthify and with just over 20 active community service partners where this clinical-community linkage is established and closed-loop referrals are made, we increase our chances of meeting the patient’s needs or at least understanding how we can do so,” Dickson said.

“In one year, unnecessary emergency department visits declined by 15% for Medicare and Medicaid patients,” she said. “According to preliminary estimates, this intervention reduced the cost of unnecessary visits by as much as $1 million – a 15% decrease in just one year. These initial findings suggest that this partnership already is making a significant positive impact on improving the quality of care while reducing costs.”

Patients, too, are seeing measurable results on their health and overall wellbeing, she added.

“One patient who was suffering from COPD and Type 2 Diabetes, as well as a history of substance use, had nine hospital encounters between 2018 and 2019,” she recalled. “The estimated cost of those visits was just over $82,000. Additionally, the patient reported being food-insecure and lacking both adequate housing and transportation. This is where our community navigator stepped in to assess their situation and then accessed Healthify to ensure they were connected with the appropriate community resources.”

After the patient received this assistance and better understood, navigated and accessed community and social services, the patient was rescreened and at that point, the patient reported they had access to transportation, a reliable source of food and a place to live, thanks to the navigator’s assistance and timely intervention, she said.


“This technology became our go-to resource for connecting patients to community-based social services across the board,” Dickson stated. “With the help of SDOH technology, we’ve been able to evaluate whether patients are getting the social services they need to improve their health. We have the data at our fingertips and a community of partners who help us to leverage it. We’re certainly moving the needle on the health of our community because of this technology.”

Choose a technology vendor that is nimble and customer- and community-focused, she advised.

“SDOH is constantly changing,” she noted. “You will find yourself frequently adjusting workflows, reporting formats, etc. The vendor should be flexible and eager to meet your needs, not theirs. Additionally, it should feel like a partnership. Both organizations striving to accomplish the same goal.”

The platform should be easy to navigate and user-friendly, she added.

“Potentially, many people with varying skill-sets will be using the platform,” she said. “Training should be quick and straightforward. End users may be located in a hospital or agency setting. The platform should be adaptable to different workflows.”

When thinking about this type of technology, go beyond the current project in mind, she suggested.

“Ask your team: Are there other ways this platform can be used to maximize ROI?” she concluded. “If the intention is to have community partners also use the platform, seek their feedback as well during the selection process.”

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.

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