New tool addresses health care needs outside doctor’s office

A Whidbey Island senior woman was living alone, not eating and sustaining herself with alcohol before a case manager stepped in.

She was socially isolated, had mental health concerns, chronic pain and was largely unable to feed or care for herself, yet she’d been reluctant to seek out services. She might not have gotten access to the resources she needed had it not been for a new pilot program that recently took place at WhidbeyHealth’s Freeland Clinic.

This woman’s story was included in a report about a referral system created through a partnership between the public hospital district, Island County Public Health and Island Senior Resources. The idea is to address wellness at a level beyond prescriptions, surgery or blood pressure.

The screening tool asked questions on eight topics that can have a significant impact on a person’s health, according to Tabitha Sierra, patient safety and experience coordinator at WhidbeyHealth. The questions focused on needs that could be addressed through resources readily available on the island, she said.

The six-week pilot program took place in mid-September through the end of October and involved a voluntary questionnaire given to patients at the Freeland clinic.

The screening tool will be evaluated and re-launched with some slight modifications in February, Sierra said.

The questions asked about patients’ needs regarding access to housing and utilities, ability to get to and pay for heath care, food security, social support and ability to care for self, transportation, personal safety, mental health and substance abuse.

These social and physical environmental factors can play significant roles in people’s health outcomes, according to the Centers for Disease Control and Prevention.

Participants could indicate if they had concerns over any of these topic and, separately, if they would like help. Of the 245 screens that met the minimum participation rate, 79 people asked for help with referrals.

A case manager at Island Senior Resources would follow up with these people within two business days, said Chastity Smith, director of aging and disability resources at Island Senior Resources. These follow-ups could require only one meeting but some warranted ongoing support.

The case manager position was funded by the state Accountable Communities of Health through a program designed to integrate health care and address social determinants of health.

Many of those seeking services through the program were relatively young adults, which Sierra said was surprising given the average demographics of Whidbey Island, especially on the South End.

More than 62 percent of respondents who asked for referrals were between the ages of 30 and 39, according to the data summary. Many of these people needed help to stay or get into housing or to pay for utilities, Sierra said. There were also far more requests for help from women than men.

Females were nearly twice as likely to ask for referrals. LGBTQ respondents and spouses of veterans were also groups likely to ask for assistance, according to the report. Most people who wanted help requested health referrals regarding concerns with chronic pain, ability to concentrate or overall health status.

Many people also felt very isolated and hadn’t felt like they had a person they could ask for help from before, Sierra said.

“It’s a really important opportunity to help people who don’t otherwise have someone to talk to,” she said.

Another senior female who participated had reported that her social isolation was affecting her mental health. This person was connected with medical transportation and congregate meals at Island Senior Resources, according to the data summary.

The hope is to eventually expand the program to the rest of the island and to settings outside WhidbeyHealth clinics, Sierra said.

“We’re still working on long-term sustainability,” she said.

The Freeland Clinic’s size made it possible for one person to handle referrals, but the case manager would be overwhelmed if this was offered at Oak Harbor clinics as well, Sierra said. There are also limitations to what resources are available to refer people to.

Smith said there’s a need for services such as mortgage assistance and child care resources, but nowhere to send people who want that kind of help.

She recently gave a presentation about the program at a public health conference, and Smith said her speaking partner had implemented a similar tool in an urban setting. There were clear differences in the number of available resources in that urban or suburban setting, she said.

However, she said Island County is on the cutting edge of using social determinants of health to improve public health.

“Social determinants of health are becoming rather common knowledge among health care systems,” Smith said. “What is not widespread, at this point, is actually taking a step to do something about it.”