Authors :
Presenting Author: Doreen Guilette, – Dartmouth Health
Meredith Olenec, BA, CHW – Dartmouth Health
Barbara Jobst, MD, Dr. MED, FAES, FAAN – Dartmouth Health
Shannon Donnelly, MBA, CCHW – Dartmouth Health
Bryan L'Heureux, MPH – Dartmouth Health
Elaine Kiriakopoulos, MD, MPH, MSc – Dartmouth Health
Rationale:
Background: Social Drivers of Health (SDOH) are non-medical factors, such as housing, transportation, food access, education, and financial stability, that influence a wide range of health outcomes and quality of life (QoL) risks. People with epilepsy (PWE) are often affected by comorbidities and social stressors, therefore, identifying and addressing SDOH is essential to delivering equitable and comprehensive whole person care. We examine community health worker (CHW) enhanced integration of standardized EHR SDOH screening, resource referral and tracking at our epilepsy center as an approach to recognizing patients’ social needs and connecting them with community-based resources.
Methods:
Methods: Between 1/25/25 and 7/31/25, in the Epilepsy Clinic at Dartmouth Health 46 multidisciplinary clinicians participated in a quality improvement project to facilitate SDOH identification via a standardized SDOH screening tool assigned to patients by a CHW. During this period, 2,300 patients were assigned a SDOH questionnaire via EHR patient portal. Screening assessed eight key domains: transportation, physical activity, housing stability, intimate partner violence and social isolation, utilities, health literacy, financial resource strain, and food insecurity. PWE received the questionnaire within 7 days of their scheduled clinic appointment and providers also had the option of referring patients directly to the CHW for SDOH screening during clinic visits. If a patient screened positive for one or more unmet need(s), a CHW contacted the patient to offer support and connect them with appropriate resources. Virtual CHW follow up with patients occurred one month following the provision of resources.
Results:
Results: Over a 190-day period, 2,300 patients were assigned the SDOH screener; 1,341 patients completed it, and 58.99% screened positive for at least one unmet social need. Of these, 149 expressed interests in receiving assistance; 70 later declined, reporting they had support or resolution of the need. 79 PWE met with a CHW and were successfully connected with community-based resources by phone (n=73) or in person during a clinic visit (n=6). Among PWE who screened positive, the most common reported needs were financial resource strain (71.81%), food insecurity (58.39%), transportation (45.6%) and health literacy challenges (41.61%). Additional reported needs included housing instability (32.89%), utility insecurity (12.75%), limited physical activity (8.05%), and intimate partner violence/social isolation (6.71%). Of the positive, 64 PWE were connected to resources within 7 days (Graph 1).
Conclusions:
Conclusion: Integrating routine EHR supported SDOH screening into clinical workflows has the potential to enhance holistic patient care by identifying unmet social needs and addressing health inequities among individuals with epilepsy. Future efforts at our center will include a focus on evaluating the outcomes of this CHW enhanced intervention, including referral follow-through, patient satisfaction, and impacts on clinical outcomes and quality-of-life measures.
Funding: n/a