a minimally invasive needs assessment on social determinants of health

Our LHIN is working on a project called Health Links. From what I understand, the idea is that we be looking at our health care system from the perspective of our patients with an eye on finding gaps that can be filled. I expect this to define which Social Determinants of Health are not being managed in our areas.

Social Determinants of Health are the economic and environmental factors in our lives that impact our health. Think poverty, healthy food, education, rewarding employment. There is a great resource put together by Mikkonen and Raphel in 2010 available here that explains The Canadian Facts of SDOH. Also look for ideas and a great conversation on Twitter by searching for #SDOH.

This weekend, I decided to have a good look around and see which resources are available to us as we start this new Health Links project. I came across this Ted Talk by Rebecca Onie:

Have a look. She's inspiring.

In short, Ms. Onie and her team have made it easy for doctors to prescribe things like heating, access to food, social groups. She has done this by putting volunteers armed with Google and agency information into the waiting rooms of city clinics. Doctors write a prescription for whichever socially powerful item would help their patients, the patients hand these to the volunteers. Rather than going with the culturally accepted and  She calls her volunteers her army of college students. I love this. Especially because those students are learning so much more than they could get in any sociology class.

But I'm in rural Ontario. I don't have legions of college students. If I did, which waiting room would get enough traffic to make the most use of their time? How could I possibly get resources to ALL my patients, spread all over our LHIN? And how do I make it easy for our docs to get this done? They are busy and have a huge spectrum of practice.

First, we are hopefully going to have funding to add a new outreach position to our team.

To figure out how to use this person to the greatest benefit for our patients, I'm suggesting Dear God letters (where GOD stands for Guardian Of Determinants of health). Every time one of our docs, nurses or nurse practitioner has an interaction with a patient where they find a SDOH need, they send an EMR message to the initials GOD with the patient's specific need. It's faster than writing a script, easier than a referral, and with our EMR it means that all these needs end up in one mailbox where we can figure out how best to serve both that individual patient and our patient population as a whole.

An example might be:
Dear GOD, this pt needs someone to help them fill out ODSP forms.

Or

Dear GOD, can we find a way to pay for this pt's gas to get to his referrals in Big City?

The success of this minimally invasive assessment will depend on:
1. the team's willingness to write Dear GOD letters
2. a guardian who has mad Google skills and is willing to think about things differently than we already do here in our LHIN
3. community resources sharing their information and being willing to let our guardian pick their brains
4. patients feeling that they can ask the health team for help for things they've never asked for help with before, and the health team reciprocating that feeling

Maybe patients should watch this video first to get an idea about what we are hoping they can open up to us about.

What do you think? Is this something we can do?