About CHRT

Learning Action Network Coach: Addressing social health needs in chronic and preventative disease

June 2021 – May 2022
Client(s): Institute for Healthcare Improvement (IHI)
Funder: Pfizer

While understanding that the social conditions in which a person lives, works, and plays is critical to health, only 24 percent of hospitals and 16 percent of physician offices report screening for social needs. More and more, however, health systems are recognizing the imperative of understanding the social needs of their patients and helping to resolve unmet social needs that directly impact health, well-being, and equity. In order to support the journey of these healthcare organizations, Pfizer is funding work with the Institute for Healthcare Improvement (IHI) in Boston, Massachusetts, to create a Learning and Action Network. The network will support the social care integration work of three to five integrated delivery networks in the United States.

CHRT’s role:

CHRT’s executive director has been selected to participate in a multi-disciplinary national faculty team that will provide coaching and guidance to competitively selected integrated delivery networks. In this role, CHRT will:

– Equip leaders with the messaging and approaches for describing their social care integration vision and strategy to internal and external stakeholders and advise on making SDOH a strategic priority, paying particular focus to addressing equity.

– Advise on identification and implementation of social needs screening and referral tools and systems; creation of measurement and reporting strategy including plans for analysis of screening and referral rates over time; and the development, testing, and ongoing analysis of incentives for data collection.

– Coach on data analysis to better understand priority populations, including stratification methods to identify those most impacted by inequities within the system. The data-related coaching will also support IDNs to set up data analysis systems and methods that will align with approaches to rapid cycle testing, learning and improvement.

– Provide evidence-based examples and links to bright spots throughout the US as participating IDNs step through their efforts to address social determinants of health and improve equity.