Practical Resources for Addressing Social Determinants of Health

An Interview With AAFP About The EveryONE Project

Interviewer: Laurie Scudder, DNP, NP; Interviewee: Julie K. Wood, MD, MPH, FAAFP


October 08, 2018

Editorial Collaboration

Medscape &

Best Practice Strategies

Medscape: We all know that family physicians are perennially squeezed for time. What are some best practice strategies to incorporate this tool into routine patient care?

Wood: We all recognized that addressing SDoH needed to be a team-based effort. The onus could not be all on the physician. Of course, the physician is an important part of the team, and the conversation with the patient is important. But our goal was to develop a streamlined process where screening could occur, answers could be found, and need could be determined, all before the patient even reaches their family physician. So as soon as the patient comes in the door, the team is already involved. The front desk, the nurse, or the medical assistant that's rooming the patient can perform the screen. The team can identify potential concerns. Then when the family physician's ready to go in and see the patient, they can have that discussion as part of the visit.

Perhaps it's a patient with diabetes, and the staff has determined that they have difficulty with access to healthy foods. The family physician can talk with the patient a bit more about that rather than starting from scratch.

The Neighborhood Navigator gives the physician the power at the point of care to make an intervention that's meaningful for their patients.

The EveryONE Project recognized the importance of the whole team being involved in addressing this issue. The sites provides specific team-based resources to help physicians assess the resources in their own practice and develop an implementation plan.

Medscape: What is next? Once physicians have screened for SDoH, what resources are provided on The EveryONE Project website to assist with the very daunting task of integrating addressing these concerns into practice workflow?

Wood: It's always frustrating to say that we have this screening opportunity, but we don't know what to do once we've identified a problem. What we heard from respondents to our survey was: I really recognize this is a concern, but if I can't intervene, do I really want to screen? To address that, we just launched the AAFP Neighborhood Navigator, which is an online platform that the team can use to help identify resources in the community by ZIP code. We looked at existing tools and customized it on the basis of what our members told us they needed. The navigator addresses the major social determinants. It is a very practical resource, and it lets our members work at their own level. If they find something in their community that's not in the navigator, we can verify that resource and add it. The navigator gives the physician the power at the point of care to make an intervention that's meaningful for their patients.

Information is available in over 100 languages. It helps with transportation, financial issues, and legal issues. It allows physicians and their teams to create an action plan specific for the patient.

The navigator and its tools are also available on our patient-facing site So patients can use it directly, or physicians can use it at the point of care in the office.


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