ew Americans face additional challenges to their health compared to native-born Americans, even when within the same socioeconomic class. These challenges, most commonly known as social determinants of health (SDOH), can not only be harmful to an individual’s health, but make it more difficult to obtain healthcare.

To better understand the challenges faced by New Americans, we are collecting data within our electronic health records (EHR) through social determinant of health screenings. With more data, we can focus our care and our community outreach efforts to better meet the needs of our patients. 

Recent data from 2020-2022 shows higher rates of food insecurity (8.6% vs. 5.4%) and transportation issues (7.5% vs. 3.7%) among patients identified as New Americans compared to those not marked with that identifier in the EHR. New American patients have shared sentiments of difficulty with the public transportation system as they adjust to their new environments and find time to utilize it between work and responsibilities. Many new American patients have also shared difficulty accessing familiar foods and getting to a grocery store, especially if they may be living in a food desert.

With rising food prices, many New American patients have expressed difficulty accessing familiar dry foods they can cook. They often find that local food pantries lack items they are accustomed to, as they are not used to canned foods. Additionally, grocery shopping is challenging without a car, as it’s difficult for them to carry groceries on the bus. One senior patient in her late 60s even shared that she prefers eating fast food daily because it's easier to walk to McDonald's, buy food, and eat there than to go grocery shopping and struggle to bring the items home.

Studies suggests that interventions to lessen the risks of mental ill-health can start with the prevention of social isolation. Historical data suggested that New Americans had lower rates of social isolation, but those screenings were less vigorous. We don’t currently have the resources to address social isolation adequately, so we have discontinued gathering this data formally through the screening tool.

As we continue to analyze SDOH data across different demographics, we can better identify disparities and resource needs. This analysis is always ongoing, always shifting to ensure we are offering the resources our community needs. 

New American patients have shared sentiments of difficulty with the public transportation system as they adjust to their new environments and find time to utilize it between work and responsibilities. Many new American patients have also shared difficulty accessing familiar foods and getting to a grocery store, especially if they may be living in a food desert. "New American patients have shared sentiments of difficulty with the public transportation system as they adjust to their new environments and find time to utilize it between work and responsibilities."

From a Local Level: Managing SDOH Disparities 

The Redwood Health Center is the primary care home to many new American patients. So far, the clinic has done well regarding effective communication between providers, care management teams, and external resources to address patient needs identified through SDOH screenings. If internal resources for our patient's needs don’t exist, patients are connected to culturally applicable and vetted external community resources for assistance. It is common for patients to utilize external community resources for childhood and adult education, insurance enrollment, legal assistance, food assistance and transportation.  

Redwood Health Center has also begun working closely with the Department of Health and Human Services (DHHS) to address the needs of children and families through a partnership with the Zero to 8 Care Coordination team. This began as Redwood providers identified that their patient population had a lot of support needs, like additional health promotion and education resources, help with childcare, or access to baby formula. The Zero to 8 team comes to the Redwood Health Center to offer a range of services including education and behavioral health for kids even up to age 18. 

Initiatives like the Refugee Transportation Program by Medicaid plans such as Healthy U have also been instrumental in addressing transportation barriers for patients. This, along with other programs like UTA Travel Training, are so important to ensure patients can get to their appointments. It has taken time to build these trusted partnerships and programs, and they are just as important as the medical aspect of patient care. 

A Constant Work in Progress 

We understand that caring for patients with health disparities and dynamic SDOH can increase the complexity of a medical appointment for providers. That is why the Community Physicians Group Quality team works with clinic teams to create more automated processes through the EHR and screening tools to monitor, track, and standardize resources. The goal is to make it easier for providers to get their patients what they need.  

For instance, the after-visit summary (AVS) automatically includes information on community resources such as United Way and 211. The provider doesn’t need to take any extra steps to provide their patients with information they need. The Quality team is always looking for additional resources to include in this AVS resource list – please reach out with suggestions! 

Our teams are committed to improving support for patients facing health disparities. As the SDOH screening initiatives continue, we will be gathering and analyzing data on how and when our patients are utilizing the resources we provide them. We are striving to be open-minded and flexible so we can adjust this program to best fit our community’s needs and follow the data to achieve the best outcomes.