An Electronic Health Record-Based Platform for Social Needs Assessment and Navigation Services: Preliminary Results...

The study team has developed an electronic health record-integrated platform, including a clinical decision support and closed-loop referral tool, to identify patients with social needs and to provide assessment and navigation services. This paper presents the results of the first 6 months of the study assessing the effectiveness of this platform.

This was an RCT.

This study took place in 5 primary care clinics at the Johns Hopkins Health System and 5 community-based organizations participating in the digital closed-loop referral system.

This study included African-American adult (aged ≥18 years) patients living in socioeconomically challenged neighborhoods in Baltimore City.

The study compared the electronic health record-integrated digital platform with the standard of care.

The main outcome was a change in the number of identified social needs from enrollment to 3-month follow-up, comparing intervention with control groups.

During the first ∼6 months of the study, the authors reached out to 1,648 eligible patients, 92 (5.59%) of whom enrolled and consented to join the trial. Among the intervention group, using only information provided by the electronic health record-based digital platform, the authors identified 25 patients (56.82%) whom they deemed not to require further social needs assessment (Intervention Group A) and 19 patients (43.18%) in whom the information provided in the digital platform suggested that high social need may be present (Intervention Group B). This latter group was deemed to require further in-depth social needs assessment and subsequent social services navigation support, potentially including referral to the participating community-based organizations. More patients in Intervention Group B than in the control group and Intervention Group A experienced a decrease in social needs documented by providers across the Johns Hopkins Health System outside the study setting (8 patients [42.11%], 11 [22.92%], and 2 [8.00%]; p=0.021) or by the study team (3 patients [15.79%], 1 [2.08%], and 1 [4.00%]; p=0.078).

These preliminary findings show that structuring a social needs assessment and intervention within clinical electronic health records can improve the social needs assessment and intervention process.

This trial is registered through the NIH on clnicaltrials.gov (NCT05574699).