Background: Health-related social needs, such as food insecurity, unstable housing, and interpersonal violence, increase the risk of developing chronic conditions and reduce individuals’ ability to manage these conditions. ANCHOR (Addressing the Needs of the Community through Holistic Organizational Relationships) is a CMS funded initiative at NYP-Columbia that tests the hypothesis that screening and referring patients in the ED can achieve the triple aim of reducing healthcare costs, decreasing emergency room utilization, and improving population health outcomes.
Objective: To test the feasibility of screening for social determinants in an urban emergency department and referring patients to downstream community service providers to address social needs.
Methods: The ANCHOR pilot launched in three NYP-Columbia emergency departments (one pediatric ED and two adult EDs) in Northern Manhattan in June 2018. The pilot utilized screened patients along five domains: inadequate and/or unstable housing, food insecurity, transportation needs, utility needs, and interpersonal violence. The model used an information technology (IT) platform to screen emergency department patients prior to their clinician visit, stratify patients according to risk level, and generate referrals to community service providers
Outcome: Since June 2018, 389 patients were screened across three NYP-Columbia emergency departments. 238 patients (61%) screened positive for at least one social need. Most common needs were food insecurity (40%) and housing (41%), with 20% identifying housing stability needs and 29% identifying housing issues. 50 patients (30%) were successfully navigated to a community service provider. 30 patients (21%) opted out of navigation services prior to referral and 28 patients (20%) were unable to be contacted.