CCHEq partnership results in thousands of health equity screenings

They’re called social determinants of health, or SDOH — aspects of daily life that can greatly affect well-being but fall outside of traditional medical concerns.

Among public health professionals, awareness continues to grow about the important role played by these factors, which can endure through generations and drive heath inequities. How best to assess these challenges and effectively respond remains something of an unsettled question.

In upstate New York, one possible solution comes from a growing initiative that started with a collaboration among the Cornell Center for Health Equity (CCHEq), the Cornell Master of Public Health Program and a local healthcare system.

During its short tenure, the program has already provided thousands of SDOH screenings while linking community members to applicable resources. By the end of 2024, project leaders expect participating primary care practices to rise and participating community-based social services organizations to jump from 2 to 17. Such an expansion could mean 60,000 screenings a year.

“Healthcare in the U.S. is moving in this direction, so we’ve kind of had a jumpstart,” says Cornell’s Lara Parrilla, who helped start the program and recently presented early results to regional health and human services providers. “It’s a tremendous culture shift that we were able to initiate.”

Partnership with Cayuga Health Partners
The project’s origins trace back several years, when Parrilla accepted a position jointly funded by Cornell and Cayuga Health Partners (CHP), a network of hospitals and practices spanning Tompkins, Schuyler, and Cortland counties. Through her new role as CHP’s community and academic partnership manager, she met a number of primary care providers and spoke with a range of patients.

She realized that the doctors increasingly saw social determinants of health as a driver of poor health outcomes but were often uncomfortable broaching the topic. Not only did they lack an effective and consistent way to screen for specific challenges, they were also unsure where in the community they could send patients for support.

Many patients, it turns out, were open to having conversations about the challenges they faced but weren’t sure their doctors were interested. They also didn’t know if their doctors could do anything to help.

To address the disconnect, Parrilla turned to the Center for Health Equity, where she serves as co-associate director of student & community engagement. She consulted with co-director Jamila Michener and member Amelia Greiner Safi, a professor of Social and Behavioral Sciences and Public Health Practice.

“Having the center involved in a local project can really change what’s possible — the scope, the nature and the impact of it,” Michener says, citing the Cornell resources the team can marshal. “It allows projects to move further and deeper into the community.”

Community engagement impacts
Michener also touched on the importance of Cornell’s work in Tompkins County. “The local work is really quite crucial, and in many ways, it’s the heartbeat of our public and community engagement,” she said. “If you can’t impact the communities you’re embedded in, then it’s that much less feasible to imagine you’re going to have an impact beyond that.”

Soon equipped with a grant from Cornell’s David M. Einhorn Center for Community Engagement, in 2020 Parrilla recruited a few public health graduate students and members of the center’s undergraduate student chapter. In collaboration with Cayuga Medical Center’s Internal Medicine Residency Program, the team identified six core areas to include in the screening and referral pilot program: childcare and adult education, social support, finances, food, housing and utilities, and transportation.

From there, the team created a poster for each topic and a brochure listing available community resources. They also standardized the screening approach, adapting a publicly available tool to create a focused, one-page questionnaire at a 5^th-grade reading level.

As a pilot, the posters and brochure were placed in the residency program’s outpatient clinic, chosen for its large portion of Medicaid patients and ties to Cornell’s internal medicine residency program. The questionnaire went to new patients, as well as patients coming for annual well visits.

While leaving it up to patients to actually reach out for services may have avoided discomfort at times, the choice was also a result of the project’s limited initial resources, Parrilla says. When it gained the opportunity to go further, the team brought in two community-based organizations to help arrange needed support (the Human Services Coalition and the Cornell Cooperative Extension, both of Tompkins County), with CHP providing access to its secure online referral platform.

The team then created a workflow tying everything together. When doctors identify a social need, they make a referral with the patient’s permission to one of the designated organizations. The organization decides if it can provide the support directly or needs a partner.

Once services are given, notes go into the patient’s electronic medical record for the next medical visit, where the doctor can ask about the impact. The doctor may also adjust care, prescribing a non-refrigerated form of insulin or other substitute, for example, if a patient with diabetes has unstable housing or can’t afford to pay the electrical bill.

“One of the things it does for patients is increases their trust in their providers,” Parrilla says. “They see, ‘Oh, my provider actually cares about my overall well-being, not just the clinical things I came in for.’”

Recognition and insights
Already, the program has won an award from Excellus BlueCross BlueShield. It has also generated a trove of early but useful insights. Among screened patients, nearly a quarter have at least one need — social support is the most common, followed by finances, housing, transportation and food. Certain populations are more likely to have at least one need: Medicaid recipients, members of the LGBTQ+ community, and Black/African American patients.

When asked about future goals, Parrilla rattles off a list that goes beyond bringing in more practices and community organizations: Increase the screening rate. Use CHP’s “health equity dashboard” to further identify and tackle health disparities. And track referrals more deeply, gaining data on what barriers to services remain and what impact completed referrals achieve.

“We want to know when they’re successful and when they’re not successful,” Parrilla says. “When they’re successful, we want to see the extent to which this helped move the needle on health outcomes.”