The Marshfield Clinic Health System (MCHS) has an ambitious plan to advance health equity by screening for social determinants of health (SDOH) the 320,000 patients it sees each year across its 30,000-square-mile rural Wisconsin coverage area, and to then connect patients with community-based agencies who will help provide them with the social services they need.

Health equity initiatives

Learn how organizations across the country are working to center health equity in their COVID-19 responses.

Making it work requires data and a universal information technology system that can access or enter that data from any of Marshfield’s 60 locations and from the community organizations which with they partner. Also needed is a long-term commitment from its leadership that the system will remain engaged in this work.

The first two elements are being worked on, said Jay Shrader, Marshfield’s vice president of community health, wellness and health equity, but the third component—support from MCHS CEO Susan Turney, MD—is firmly in place.

“Dr. Turney is amazing. She gets it, and she has been pushing this for as long as I can remember,” Shrader said. “Having executive leadership support when there are so many other competing priorities is critical.”

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Marshfield population health models show that, when it comes to improving community health, the focus should be on activity outside the walls of the health system.

An AMA Health System Program member, Marshfield is partnering with a company called NowPow, whose name derives from the saying “knowledge is power.” The Chicago-based firm builds personalized community-referral platforms mapping needs and services.

“They're helping us create community-based networks of care,” Shrader said. “It would be foolish for us to think that a health system is going to solve these things without partnerships, without subject-matter experts or without technology.”

Those networks are being organized as formal partnerships that can exchange data and will result in patients being referred to organizations as if the patient were getting a prescription.

“NowPow is going to help us to create workflows and a platform that creates a systematic approach to screening our patients,” Shrader said. The more efficiently and easily data entry and other tasks fit into staff workflow, the more likely the system will be used, he added.

The SDOH data will help measure a community’s broadband internet access, level of food security, and its education, housing and transportation needs. MCHS has an ambitious target to screen 50,000 patients for SDOH by this time next year.

Some of this health equity work has been going on for years at Marshfield, most notably in its community resources department and its health plan, “but the reality is it's been fragmented,” Shrader said.

Marshfield is working with its EHR vendor to fully integrate the NowPow platform so that the data that’s collected flows into their electronic health record system.

“We first have to get our hands around the data so we understand what problems we're trying to solve,” Shrader said, adding that the data is needed to assess where to get started and how Marshfield can make the biggest impact.

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There is plenty to do while waiting for the IT infrastructure to be completed, Shrader said, adding that there will be several soft launches to test and fine tune their operation before it fully goes live.

“There is significant training that needs to occur—not just on how to utilize the software or the platform—but also education on the significance of how social determinants of health impact quality and impact clinical care,” he said. “That's going to be our biggest lift to date—getting people to understand the significance of things like how lack of safe housing impacts care.” Training also is needed to “build competence and confidence for people to have these conversations, because it is introducing a topic that many clinicians, care teams need help having,” Shrader added.

Learn about the AMA Center for Health Equity and the AMA’s strategic plan to embed racial justice and advance health equity.

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