Automation Workflow for Social Determinant of Health (SDOH) Screening

Operationalizing SDOH screening at scale automates a critical but administratively burdensome compliance and care gap activity. The workflow ingests patient-reported data from tablets, portals, or staff-administered tools, applies validated scoring algorithms, and flags positive screens for food insecurity, housing instability, or transportation needs. The business value is direct: it transforms a manual, often skipped process into a systematic, documented component of care, supporting value-based reimbursement and reducing the labor cost of manual screening and data entry by clinical staff.

Implementation requires tight integration with the EHR (Epic, Cerner) via FHIR APIs for patient context and documentation. The orchestrator, built on a framework like LangGraph, manages state, calls scoring logic, and invokes a geospatial resource database. Critical controls include a mandatory clinician or community health worker review gate before referral transmission, ensuring appropriateness. The system must produce an explainable audit trail linking the screen, score, matched resource, and review decision to satisfy compliance and create a defensible record for quality reporting.

This workflow automates a critical yet repetitive bottleneck: manually administering SDOH questionnaires, interpreting free-text responses, and matching needs to community resources. The operational upside comes from standardizing a CMS-mandated process, reducing nursing intake time by 70%, and creating a structured, auditable screening history that supports value-based care contracts and population health initiatives. Savings are realized through labor leverage and improved coding accuracy for risk adjustment.

Implementation integrates directly with Epic or Cerner via FHIR APIs, using a LangGraph orchestrator to manage specialized agents for questionnaire logic, NLP scoring, and geospatial resource matching. Controls include mandatory clinician review of positive screens before referral orders are placed, with all agent decisions logged to an immutable audit trail showing the rationale for scores and matches. The rollout is sequenced by clinic site, with continuous monitoring for screening completion rates and referral acceptance to validate workflow efficacy and compliance.

This workflow automates the administration, scoring, and interpretation of standardized SDOH screenings within the EHR workflow. It eliminates manual form distribution, scoring, and data entry, directly addressing the operational bottleneck of integrating SDOH into routine care. The savings come from reduced nursing and social work administrative time, improved screening rates for quality reporting, and earlier intervention that can lower downstream utilization costs. Implementation requires orchestrating triggers from the EHR, an LLM agent for scoring and rationale generation, and integration with community resource databases like NowPow or Aunt Bertha.

Phased delivery is critical for clinical safety and adoption. Phase 1 focuses on non-critical screenings with human-in-the-loop review for all positive flags, building trust in the agent's rationale. Phase 2 introduces auto-referral for low-risk, high-confidence matches (e.g., food pantry referrals) while maintaining clinician oversight for complex needs like housing. Phase 3 enables full autonomous operation with continuous monitoring of referral success rates and model drift. Controls include explicit approval gates in the EHR, a dedicated explainability dashboard showing scoring rationale, and immutable audit logs linking every decision to source data for compliance audits.

This workflow automates the administration, scoring, and referral logic for Social Determinant of Health screenings within EHR workflows. It eliminates manual form distribution, data entry, and missed referral opportunities, directly improving care quality and supporting value-based reimbursement. The operational upside comes from standardizing a fragmented process, capturing structured SDOH data for population health, and generating a defensible audit trail for CMS reporting and accreditation. Implementation requires tight integration with Epic or Cerner, orchestration logic for patient outreach, and a rules engine for community resource matching.

Governance is enforced through a dedicated compliance layer that logs all screening logic, scores, and referral decisions. This creates an immutable audit trail, essential for defending against audit findings and demonstrating program efficacy. Controls include configurable approval gates for high-risk referrals, bias checks on scoring algorithms, and real-time dashboards for program managers. A phased rollout starts with a single clinic or patient cohort, validating data quality and referral accuracy before expanding. Monitoring focuses on screening completion rates, referral acceptance, and time-to-intervention, with exception routing to social work or care coordination teams.

An automated SDOH screening workflow directly addresses the operational bottleneck of manual screening, scoring, and resource matching, which is labor-intensive and prone to documentation gaps. The compliance upside comes from systematically capturing every screening event, the clinical rationale for positive flags, and the evidence trail for community resource referrals. This creates a structured, auditable history that satisfies CMS reporting requirements (e.g., for AHC HRSN screening) and supports value-based care contracts by demonstrating proactive social risk management.

Implementation requires integrating the orchestrator (e.g., LangGraph) with the EHR (Epic, Cerner) for patient context and to write back screening results. The architecture must include a rules engine for scoring validated instruments (PRAPARE, PHQ-2), a geospatial API for resource lookup, and a justification layer that cites the specific screening question and response that triggered each action. Controls include mandatory human review for high-risk escalations, configurable approval gates for referrals, and real-time dashboards for compliance officers to monitor screening completion rates and audit trail completeness against organizational policy.