NYC Health + Hospitals Expanding Social Needs Screening Capabilities

NYC Health + Hospitals, the largest municipal healthcare system in the country, says it is making steady progress in screening patients for social needs and integrating tools into its EHR to make that screening easier for clinicians. 

The health system has integrated a tool from a vendor called findhelp into Epic to connect patients to community resources. The tool includes a social service referral platform and network of more than 7,000 programs – including food assistance, transportation, and shelter – serving New York City that is regularly updated to ensure accuracy. 

NYC Health + Hospitals’ social needs screening program screened more than 250,000 primary care patients for social needs in outpatient settings in 2023. Over one in four patients who were screened last year wanted assistance with social needs. The new platform will help health system staff refer patients to community resources. Later this year, NYC Health + Hospitals, which has 11 hospitals and more than 70 patient care locations across the city’s five boroughs, will expand its social needs screening to include inpatient settings.

“As doctors, we know that too often our patients are struggling with making ends meet, and that is a particularly frustrating barrier to getting or staying healthy,” said Nichola Davis, M.D., M.S., vice president and chief population health officer at NYC Health + Hospitals, in a statement. “This new referral platform and patient-facing website for staff is a powerful new tool in our toolbox to help our patients connect with community services and resources.”

Findhelp enables NYC Health + Hospitals staff to generate automated resource recommendations after completing the Social Determinants of Health screening tool in Epic. The recommendations are tailored to where patients live and is then added to the paperwork that patients receive after a doctor’s visit. Staff will also use the findhelp platform to search for community-based resources to address patient needs and can share them with patients via text or email in their preferred language. They will also send closed-loop referrals to select community-based organizations to follow-up with patients and connect them to care. 

Patients can also access findhelp through a new website to find local community-based organizations that offer social services, such as food assistance, transportation, shelter, and ESL and job training programs. Patients can access the site through Epic’s MyChart or directly from the NYC Health +. Hospitals homepage by clicking “Find Resources in My Community.”