SDOH Screening Agent

The work it takes off your plate

Social needs such as food insecurity, housing instability, and transportation barriers drive utilization but are inconsistently screened, poorly coded, and rarely closed with successful referrals. Staff lack time to administer standardized instruments, document ICD-10 Z-codes, and navigate fragmented community resource directories. The SDOH Screening Agent standardizes capture across visits and outreach, codes social determinants, matches patients to community resources, and tracks referral completion so social care is measurable and actionable.

How it works

The agent administers or retrieves SDOH screens, maps positive findings to Z-codes and domain severity, recommends community-based organization (CBO) referrals, and monitors whether needs were addressed. Results flow into the EHR problem list, care plans, and population health analytics for risk adjustment and equity reporting.

1. Step 1: Trigger and Capture SDOH Screens

   • Identify patients due for screening by visit type, annual gap, or high-risk flags
   • Deliver standardized instruments (e.g., PRAPARE, AHC HRSN) via portal, kiosk, or staff workflow
   • Ingest free-text social notes and prior positive screens for longitudinal context

   Result: Completed SDOH assessments linked to the encounter with source and timestamp.

2. Step 2: Code Domains and Severity

   • Map positive responses to social domains: food, housing, transport, utilities, interpersonal safety, and employment
   • Suggest ICD-10 Z-codes and LOINC screen codes with coding confidence
   • Score urgency based on acuity, utilization impact, and patient-stated priority

   Result: Structured SDOH profile with recommended codes ready for clinician or coder confirmation.

3. Step 3: Match Community Resources and Refer

   • Search CBO directories by domain, ZIP, language, and eligibility rules
   • Generate referral packets with consent, contact details, and need summary
   • Offer warm handoff tasks to care navigators for high-severity needs

   Result: Referrals submitted or queued with matched resources and patient consent captured.

4. Step 4: Close the Loop on Social Care

   • Track referral acceptance, appointment kept, and need resolution status
   • Re-screen after interventions and update care plans
   • Report domain prevalence, coding rates, and closed-loop referral performance

   Result: Documented social care outcomes feeding equity dashboards and risk models.

Why use it

• Standardized Screening. Consistent instruments across clinics and virtual visits.
• Coding Accuracy. Reliable Z-code suggestions improve documentation and risk capture.
• Resource Matching. Domain- and location-aware CBO recommendations.
• Closed-Loop Referrals. Know whether food, housing, or transport needs were met.
• Equity Analytics. Domain prevalence and resolution rates by population segment.