In part two of this webinar series, learners will be introduced to the principles and values of effective team-based care. The foundations of care teams and tools and resources will be presented to support the ongoing evaluation of existing care teams. Care team communication and workflows will be discussed, and participants can learn promising practices of organizational integration of case management, community health workers, pharmacists, and social workers for supporting those with unaddressed social risk factors. 

Learning Objectives

1. Explore promising practices for mapping an SDOH screening workflow and operationalizing other screening processes. 

2. Describe roles and responsibilities for SDOH screening to organize care team optimization.

3. Identify tools and resources to ensure consistency, accuracy, and complete data capture when operationalizing SDOH screening workflows. 

In part three of this webinar series, participants will learn how to support patients with SDOH needs by referring them to community-based organizations and closing the loop on those referrals. Presenters will demonstrate creating a referral process using the care team and patient input for optimal and reliable execution. In addition, learners will understand the importance of data sharing and governance practices between health centers and community resources.

Learning Objectives

1. Arrange and pilot workflow and staffing processes to refer patients to SDOH supports 

2. Demonstrate strategies to establish resource networks that align with health equity frameworks for referral management and integration of holistic care 

3. Recognize tools to sustain the implementation and evaluation of referral processes