Evidence-based screenings for social needs.

Little boy playing in a classroom
How AWARENESS Works in the Alliance Model:

Using SelectHealth claims data, risk stratified lists of SelectHealth Community Care (Medicaid) members are created and shared based on attribution to participating healthcare and behavioral health organizations. These lists of high-risk members are shared monthly with Federally Qualified Health Centers, Local Mental Health Authorities, and Intermountain Clinics. In addition, flags built into Intermountain Healthcare’s electronic health record alert emergency departments when these members are admitted.

These SelectHealth members are considered Alliance participants when they consent to a social determinants of health screening. Using the SEEK screening tool for pediatrics (age 0 to 5 years old), and the PRAPARE screening tool for school-aged children to adults, participants from the risk stratified list are screened for social needs in clinical settings. These screenings also are conducted by SelectHealth care managers over the phone if the participant is not attributed to a primary care provider.

Screening for social determinants of health in a clinical setting provides opportunities to introduce and reinforce relationships between healthcare providers and community-based organizations that provide social services. Community organizations can offer expertise in social service areas and in return healthcare providers can identify people who are need of these services.