Jackson County Medical Center in Alabama has implemented a Social Drivers of Health (SDOH) assessment as part of their revamped discharge planning process. Using the Evident EHR platform, the team designed a discharge planning interview that included SDOH questions. Now, when patients are registered, their REAL data is collected, and once they are admitted, the discharge planner conducts a one-on-one interview within 24 hours of the patient’s stay. This process gathers information about home environment (e.g., family support, issues with mold or lead, accessibility), homelessness, food insecurity, transportation and more.
To address these social drivers, Jackson County Medical maintains a list of local resources such as food pantries, nutritional centers and mental health services to meet patients’ needs. These resources are compiled through a quarterly partnership meeting, which includes local hospices, pharmacies, home health, physical therapists, nutritionists, the area agency on aging and the women’s center.
Jackson County Medical has also moved to include health equity in their strategic plan. In collaboration with managers and directors from various departments, the center committed to reducing disparities by identifying vulnerable populations, training staff, and collecting REAL data and SDOH data.
The number of patients with disparities and needs is tracked alongside what resources get used to determine trends. Each month, the team compiles a report to analyze this data and ensure their resources are sufficient for the need. Leadership will review the disparities data on a yearly basis to understand accomplishments, what should change, and what work needs to be carried out. Additionally, Jackson County participates in local and national collaboratives, health fairs, health partnerships and rural health networks to gain knowledge and share resources with the community.
Jackson County’s participation in the Health Equity Network (HEN) workgroup provided building blocks to conduct this work, allowing them to better understand the Centers for Medicare & Medicaid Services (CMS) and Joint Commission requirements and implement best practices.
Jackson County Medical Center team member Billie Ann Sellers said it is key to take this work step by step. “Break it up and take it one step at a time,” she said. “What do I need? Who do I need for this? Identify who makes more sense collecting the information. Divide up the work, especially for small hospitals whose people are already juggling multiple roles.”
She also said it is important to “Really listen to the population you are serving to determine their needs.”