Leigh Caswell and Danielle Lucero presented on Social Drivers of Health at the 2024 New Mexico Communities Joined in Action Conference. Leigh is a Steering Committee member and VP of Community and Health Equity with Presbyterian Healthcare Services, and Danielle is the Senior Program Manager leading the Presbyterian Healthcare Services Social Drivers of Health Collaborative.

Abstract from presentation:

Screening patients for social needs, referring to community partners, and addressing resource gaps in the community are all challenges health care systems are facing. We propose a breakout session focused on our process to universally screen and address health-related social needs (HRSN) across 9 hospitals and 30+ clinics in the state of New Mexico. We will share how we came to agreement on social need domains to screen for, how we sought approval in our system to deploy across all settings to all patients, how we implemented and have adapted training, our quality improvement approach, and how we are providing ongoing support for care teams. We will highlight our data dashboards that stratify quality measures by Race, Ethnicity, and Preferred Language (REaL) and Sexual Orientation and Gender Identity (SGN/SOGI) as well as our screening dashboard that allows us to look at screening rates, patient social needs, and demographics down to the provider level. We will share how we are expanding to a closed loop screening and referral system across our state focusing on priority geographies and populations including LGBTQIA+, Perinatal, Behavioral Health, and Native and Indigenous Communities. We will share about a statewide Social Determinants of Health Collaborative we helped launch in partnership with our state department of health and human services department to ensure we are centering our communities and equity and building a shared, statewide vision for this work, focused on ensuring all communities have the resources they need to thrive.