The social determinants of health (SDH) are the non-medical factors that influence health outcomes. These include the social, economic, demographic, and political conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping their daily life.

According to World Health Organization (WHO), “research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDH account for between 30-55% of health outcomes. Addressing SDH appropriately is fundamental for improving health and reducing longstanding inequities in health, which requires action by all sectors and civil society.”

In late 2020, Children’s Hospital of Pittsburgh (CHP) and 2-1-1 of Southwest Pennsylvania (2-1-1 SWPA) were pondering a difficult issue: how to best identify and help people who have significant resource insecurity, when they present at the emergency department (ED) for other reasons? At the time, they were running a mostly manual program, where care givers ask the patient to fill out a physical questionnaire, which is manually input by administrators. Positive response rate was low, compared with the expected resource insecurity of the population. There were also issues tracking the success of reaching these people and tracking the success of the intervention, due to data issues.

With the support of a technology partner, Sensez9, a mechanism has been created to improve response rate and ensure that interventions are not only consistent but achieve results. Patients now indicate resource insecurity through a cell phone application interface, accessed through a QR code, which will be given to the patient, and placed strategically throughout the ED. They fill out their needs, and are immediately taken to service provider options, through the new ‘2-1-1 App’. They can find service provider locations, contact them directly, or even schedule appointments, as needed, through the app.

The app also triggers follow-up from 2-1-1, scheduling phone call follow-ups to make sure that they receive the help they need. Finally, information about an individual’s needs is recorded over time, and patterns will be used to improve proactive service offerings.