SARAH: Welcome back to the Southeast Ohio Quality Improvement Hub video series. Today, I am joined by one of my favorite primary care doctors, Dr. Jessica Hone, from our Nelsonville, Ohio Health practice site, Primary Care. I told her she could introduce herself, but I just introduced her, so she doesn't need to introduce herself now. JESSICA: Hello. SARAH: Hello, Dr. Hone. Thank you for joining us today. JESSICA: You're welcome. SARAH: I know you're really excited to be here. JESSICA: Super excited. SARAH: And you came on your own free will. JESSICA: Yes. I was volun-told to arrive here by the one and only Sara Adkins, and so I participated. SARAH: And here you are. Look how good it is. It's all good. JESSICA: Yay. SARAH: Fantastic. Well, I'm happy that you're here, so it's very nice. So today, we are going to talk about the social determinants of health screening that is being asked when patients come into their appointments. And we have seen it, and it is quite extensive, and the Nelsonville office has done a really excellent job with our SDOH screenings. So we asked Dr. Hone to come in and talk to us a little bit about the history and what they've done so far with where they started with SDOH screening, what they started with, and then moving on to where we are now. So I would love for you to tell us, where did it all start? Where did it start? JESSICA: So we started asking social determinant of health questions when we partnered with the Southeast Ohio Food Bank- for their food prescription project. And that was in winter of 2025. So we just asked the two food security questions as part of the rooming process for the patient visit, and we tried to get that done at every office visit. So the medical assistants and nurses were already in the habit of asking those two questions at the beginning of every office visit. SARAH: That's great. JESSICA: If one or the other of those two questions flagged positive, then that would trigger me to ask additional questions about food insecurity and offer the patient a prescription for the food prescription pantry program. SARAH: That sounds wonderful. How does that work? How did it work? Did it work okay, you think? JESSICA: I don't know exactly... how well it worked or not. SARAH: I like that. Yeah. JESSICA: So I know we referred close to 40 or 50 individuals to... a food prescription program. And we gave them information, and it was with three different food pantries, the food pantry in Athens, Nelsonville, and Logan. I'm curious to know how many of those people that we gave the food prescriptions to utilized the program. What that program was essentially, instead of the once-monthly food distribution that anyone is entitled to at a food pantry... people would be able to go either once a week or every two weeks to receive a food distribution. SARAH: I think that's really excellent. And we had talked briefly too about how that's tapered off. So why again did you think that it has tapered off at this point? I think we can talk about that. JESSICA: Probably because I'm seeing the same patient population... back again. So now that my practice is relatively full, I'm only seeing two new patients a week. And so the people have already been screened, and people that have flagged positive have already received the food prescription, whether they utilize it or not. SARAH: I think that's such a really important thing that I don't think we talk about enough is, I think once it's been done, then it's more of following it instead of having to start all over brand new. JESSICA: Right. SARAH: So I think that's a really important thing to talk about and to understand, like, "Hey, we can start this. It won't look the same the whole process. JESSICA: It's probably more front-end effort and work to get people connected to services than it is to follow up on how they're doing with them. SARAH: I think so, too. I think that that's an important thing to think about with SDOH screening, and I know it's a pretty long, cumbersome list. JESSICA: It's a long list. SARAH: It is a long list, and you had said then that Ohio Health on their KPI boards had started doing that- JESSICA: In the fall of 2025 SARAH: So how did you manage that when that started? So it's more than just your two food questions. JESSICA: Initially, there wasn't a whole lot of clarity as far as when to do that questionnaire. So what we started doing is to ask the questionnaire as part of people's annual physicals and medical wellness visits. And then we started doing that as part of the annual physicals and for chronic condition check-ins. So anytime someone was coming back for a diabetes follow-up or a hypertension follow-up or any other chronic medical condition follow-up, we would ask the SDOH questions. SARAH: Okay. Has that worked well, then? You think that's worked okay? JESSICA: Yeah. I do. I think that's worked okay. For the most part. We don't have 100%. SARAH: Well, I think it's pretty hard. JESSICA: Right. It would be hard to do that with- Ask so many questions ... some days. So we're not asking those questions for people that are there for acute visits. So those 15-minute appointment slots, we're not doing the SDOH questions. If they're there for a chronic condition recheck, we're asking the questions. Sometimes the very first time we go through the questionnaire, it takes longer. And then once patients have been asked the series, they sort of know how to respond. SARAH: I kind of like that too, though. It's like the food bank referrals. JESSICA: Right. SARAH: They already know what the questions are going to be. And again, I think then the process gets quicker as you go through, and maybe they know to expect it and know, maybe particularly this month or my husband lost his job this month- Right ... or whatever. Things change, yeah. And so they're prepared maybe to answer that when they come in, which is actually really nice. How did you do that process then? What steps did you take to implement that SDOH screening into the office? JESSICA: So before the SDOH screening, we were doing the PHQ-9 screening for mental health. Right? Anxiety and depression screening. So when patients checked in at the front desk, they were handed a clipboard with a PHQ-9 questionnaire to complete before they're roomed. SARAH: Great. Okay. JESSICA: That worked well, but when we added the SDOH questions in written form to that, patients weren't able to complete both questionnaires by the time our nurses or medical assistants called them back to be roomed. So the paper version of the SDOH questionnaire did not work well. SARAH: No. JESSICA: It seems to work best so far when the nurse or medical assistant is rooming the patients. SARAH: Okay. And take the time at that time to get- JESSICA: Right SARAH: questions answered. Okay. So if they flag positive for something, what are your next steps? JESSICA: If they flag positives, what I generally do is place a referral to social work. So I bring it up to the patient, and I say, "Hey, we have social workers and case managers that work with Ohio Health that might be able to connect you to some community resources that could help you with this issue you're having. Can I place the referral?" So I always get the patient's permission to do that, and to tell them to expect a phone call- SARAH: That's great ... JESSICA: from that individual. And they are on the ball. For the most part, the patient is called the same day or next day after I place the referral and given a list of resources over the phone, and then the social worker or case manager also sends the same list of resources to their MyChart for them to reference later. SARAH: That's fantastic. And that's easy, too. JESSICA: Yes. SARAH: So that way, you're not navigating what resources are out there. You're getting- JESSICA: Right. So I place a referral to social work- To social work ... case management, yeah. SARAH: Man, that's perfect. That's perfect. So that's going actually really well. JESSICA: Mm-hmm. SARAH: So the reason that we asked Dr. Hone also is that we have a dashboard, right? That everyone has access to for the QI hub, and you can actually see the increase in the social determinants of health screenings at the clinic site. You can see where it's gone way up. So I think that that is fantastic, and it's also pretty simple. I think you approach it pretty simply, which I think is also really helpful. Saves time for your other providers. JESSICA: Right. And with everything else that we're trying to do as well, so. SARAH: What do you mean? JESSICA: What do you mean? SARAH: Just kidding. All the- Only 50,000 things that you have to do. That's all. JESSICA: The blood pressure, and the blood sugar, and the- SARAH: It's fine. There's no problem here ... JESSICA: blood cholesterol, and the left toe pain, and the... SARAH: Right? No problems. There's no problems here. Not any problems. JESSICA: No problems. SARAH: No problems at all. All right. I feel like this has been really helpful. Is there anything else you want to add about maybe what you're doing in your clinic that you would like to share, or was that okay? Good? JESSICA: We also have another way to address food insecurity specifically in our office, which is a dry goods food pantry that's present in our waiting room. And that got started with a grant from one of the medical students that was rotating with me. SARAH: That's awesome. JESSICA: So one of the medical students at HCOM, Sean Dement, got a grant for, I believe it was a $5,000 grant for the year- SARAH: That's so cool ... JESSICA: to coordinate with Southeast Ohio food banks and have a dry goods food pantry. So we've got a dedicated storage area and display area in our waiting room. And it's good because not only do we have Ohio Health Primary Care at our office, we also have an urgent care. So our office for primary care is open 7:30 to 4:30 Monday through Friday. But the urgent care is open 9:00 AM to 9:00 PM every day of the week. So that access is huge. SARAH: That's fantastic. JESSICA: And people in the community are learning about it through their interaction there. SARAH: That's awesome. Good. JESSICA: Our office is also a bus stop for the Athens City Transit program. So people that use that bus stop and then walk home from the bus stop are aware of the food pantry as well. SARAH: That's excellent. JESSICA: After that grant expired, the first year, we received additional funding through the Heritage Foundation, Nelsonville Branch, to continue the Dragons' Food Pantry. SARAH: So did you apply for that then? Did you reach out to them? JESSICA: Yes. Fantastic. It was not a complicated application process at all. SARAH: Okay. JESSICA: We just said, "Hey, this is what we want to use the money for, and this is the amount of money we requested." And it was a little bit of paperwork and a green checkbox. SARAH: That's fantastic. And that's been going on for a while now, correct? JESSICA: Yes. Yeah. So we've had it about two years now- for the Dragons' Food Pantry, and it's a pretty simple online ordering system through the Southeast Ohio Foodbank, and they deliver the food to the office. My job is to unpack it, and a lot of times, I get assistance with that from other folks in the office. SARA: Absolutely. JESSICA: Then when the shelves are empty, we have to refill them and you know. SARAH: And you don't have to keep track of who took the food- JESSICA: Nope... SARAH: and you don'e have to keep track of any of that. JESSICA: Nope. There's no administrative burden other than unpacking and restocking and ordering the food. SARAH: That's fantastic. That's awesome. JESSICA: No one has to sign in or sign out, and they just take what they need, and it's an honor system, and it seems to be working well. SARAH: I love that. That's a good option. I remember when you first started, we talked about food access being a huge problem for your patients in that region. Do you think that's helped? JESSICA: I hope it's helped. SARAH: I hope so, too. JESSICA: It's not hurt anything. SARAH: That's so true. JESSICA: That's about all you can do sometimes. SARAH: That's a really great way to say it. It's so true. It's hard to know. JESSICA: Yeah. Especially access to fresh fruits and vegetables. And that's not something that we're providing. Right. So we've got canned vegetables and fruits, but we're not done yet. We've got plans. So plans hopefully in the future for frozen and refrigerated items as well as fresh produce availability. But that's going to be in the works over the next couple years. SARAH: Those are hard. There's different regulations through the food bank for those, or it just looks different, so I get that. Well, I think it's fantastic. Thank you so much for joining us today, Dr. Holmes. JESSICA: Thank you for having me. SARAH: It was a lovely conversation about social determinants of health. There you go. All right. Thank you so much for joining us. This has been a production of the Southeast Ohio QI Hub video series. Have a good day.