Screening for social determinants

At Northwest Permanente, a Portland, Ore.-based medical group of more than 1,400 physicians, a 15-year-old female patient, “Jennifer,” visited the Kaiser Permanente Emergency Department 34 times in an 18-month period. Diagnosed with Type 1 diabetes, the girl had developed major depression. Suicide attempts took her to the ED twice, and her other visits were due to symptoms of uncontrolled sugars.

Rather than simply treating the diabetes and depression, the medical team began digging deeper into Jennifer’s life. She had been missing school regularly. She lived with her brother and her mother, who speaks only Spanish and works two jobs, keeping her away from home most of the time. Their apartment had holes in the floor, and mold and mildew in many corners, says Imelda Dacones, MD, president and CEO at Northwest Permanente, P.C.

Northwest Permanente connected Jennifer with a social worker who linked her and her family with a Latina community health worker. Through that community health worker, the family found better, more affordable housing and applied for financial assistance. With increased financial stability, Jennifer’s mom no longer needed to be away from home all the time.

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