A Better Tool to Address Social Determinants of Health: The Neighborhood Navigator

Paul A. Ravenna, MD


August 08, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

My name is Dr Paul Ravenna, and I'm an assistant professor of family medicine at the Northwestern University Feinberg School of Medicine in Chicago. I am speaking to you as part of a collaboration between Medscape and the American Academy of Family Physicians (AAFP). I'm going to be talking about the Neighborhood Navigator tool, and how it can provide the next step in addressing social determinants of health (SDoH) with your patients.

Although screening tools for addressing SDoH have been developed for clinical use, doctors across the country has been relatively slow in making use of them. This is despite knowing the profound impact that SDoH can have on the lives of our patients. When you ask doctors why that's the case, a lot of them will tell you, "It's because I don't know what to do with the answers to those questions."

Doctors want to feel prepared. We want to feel that we can meaningfully help our patients. We don't just want to talk about these issues, but want to help our patients work through them because we know these barriers are important. If doctors don't feel that they have the proper tools available to them, they're hesitant to approach the subject.

I would argue that we should hold ourselves to a much higher standard. I know that addressing SDoH is hard, but everything that we do in medicine is hard. The example I like to give is that of reading an electrocardiogram (EKG). Reading an EKG is a skill that requires years to master. It requires the development of the skills to read and understand the results, as well as the practical application of that knowledge. It would never be appropriate not to do an EKG on a patient with cardiac symptoms because reading it is hard.

So yes, I understand that addressing SDoH can be difficult, but I would also argue that it's much more difficult for our patients to have those meaningful factors go ignored by their doctors.

The Neighborhood Navigator tool, available on the AAFP website, can help bridge the gap between screening and identifying SDoH barriers and helping our patients address them. The tool was developed as part of the AAFP's The EveryONE Project, which focuses on providing family physicians with education and resources to address SDoH. I view this tool as a built-in asset map. Healthcare professionals and doctors have done asset mapping for years as a way to learn about the resources available in the communities they serve, and to help pair patients with those resources that might be useful for them.

The Neighborhood Navigator tool, which can be used at the point of care, uses geographic information system (GIS) technology to identify resources for patients. All you need to do is enter your patient's ZIP code, and a list of dozens, if not hundreds, of resources will be provided to help address SDoH issues with your patients. The resources are automatically broken down into categories, such as food and nutrition, education, transportation, and mental health. You can filter even further, for example, by types of insurance accepted, by whether special pricing is available, by languages spoken, by distance. It's also possible to search for more complex resources, from residential addiction treatment or detox programs to finding affordable childcare options for working mothers.

One of the unique features about the tool—one of its most powerful features, in my opinion—is that it allows physicians to address SDoH barriers for their patients in a complete manner. For instance, sometimes as doctors, we feel good about giving our patients lists of things to do, toward the end of a visit. In doing so, we may feel as if we're doing our jobs. However, those lists or suggestions, such as stopping one medication and starting another, or calling one number for a referral and another to schedule a test, can seem complicated. With the Neighborhood Navigator tool, referral sites can reach out to help patients follow up with these tasks.

With patients' consent, you can enter their contact information, such as an email address or a phone number, in the Neighborhood Navigator tool. Then a referral site can reach out and contact your patients.

The tool also features a tab that automatically keeps track of all the patients for whom you've provided resources. That allows you, as the doctor, to stay informed about the referral process. You'll be able to keep track of whether patients have made the suggested contacts, and you can reach out to the referral site. You can also remind your patients to follow up with necessary resources. With all its capabilities and conveniences, the Neighborhood Navigator is a powerful tool that helps physicians work toward addressing SDoH issues.

Any tool that has the potential to help physicians move forward in addressing SDoH barriers should be explored. That's what we did in our residency program. We had our residents use the Neighborhood Navigator tool at the point of care in their clinics. The consistent feedback that we received, even from those doctors who were getting ready to graduate and had been working in our program for 3 years, was that they still had something to learn about the community they'd been serving. All of them said that there were resources they didn't know were available to provide for their patients, and that they wished they had known about them from the beginning of their residencies.

Therefore, I think that the Neighborhood Navigator tool has the potential to make significant difference in both identifying SDoH barriers and working toward addressing them with our patients. As physicians, we understand that these barriers have a profound impact on health and healthcare outcomes. I think the Neighborhood Navigator tool is a fantastic way to start addressing these barriers.

This is Dr Paul Ravenna, on behalf of a collaboration between Medscape and the AAFP. Thank you for listening.

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