Implementation of Social Risk Epic Based Screening and Point of Care Referrals

In spring 2019, the electronic medical record (EMR) at Penn Medicine (PennChart) was updated with a new module to assess patient social needs. This “Social Determinants of Health” module uses validated questions based on the 2014 “Capturing Social and Behavioral Domains and Measures in Electronic Health Records” IOM report.

Our Center is charged with partnering across the Penn Medicine enterprise, inpatient and outpatient care settings, to develop and deploy standard practices for implementing assessments of social needs/social determinants of health (SDOH) at point-of-care with support and referral interventions for positive screens. The primary goal of these efforts is to facilitate effective care coordination, progression of care, and transitions of care across the continuum from inpatient to outpatient services, including acute and post-acute care services, and behavioral health.

Penn Medicine has also partnered with Aunt Bertha, the largest closed-loop referral network for social services in the United States that also integrates with Epic (Penn Medicine’s EMR platform), as a first tier, broad approach to addressing unmet social needs identified by the screening module.

Learn more about Health Disparities and Social Determinants of Health and Community Health

Project Key Leads:
  • Nida Al-Ramahi
  • Heather Klusaritz
  • Rosemary Thomas
  • Jaya Aysola
  • Enterprise-Wide Workgroup

Key Partnerships