Dr. Rama Peri Improves Patient Outcomes Using SDOH Screening Tool

Rural Delaware, Sussex County, is home to several of the nation’s most productive poultry farms. Due to that outsized labor demand, a large migrant population lives in the area. The Rosa Health Center and its Medical Director, Dr. Rama Peri, provides care for many of these residents, 70 percent of whom are uninsured.

“We opened our doors in 2015. We did no advertising, just relied on word of mouth,” said Dr. Peri, who has been ABFM board-certified since 1989. “Our patients are almost entirely Hispanic. Many lack the ability to read or write. I have an interpreter with me throughout the day to help communicate with patients.”

Earlier in 2022, Dr. Peri and her staff were looking for ways to identify the most prominent social determinants of health for their patient population and improve their health outcomes. She found inspiration from a downloadable screening tool available on the American Academy of Family Physicians’ (AAFP) website. The 15-question form addresses necessities such as housing, food, employment, transportation, and personal safety.

Once this screening tool was implemented in May 2022, Dr. Peri gained a greater understanding of the challenges facing her patients. She monitored the results and worked with staff to create action plans and allocate resources as needed. These advancements in patient care provided the foundation for Dr. Peri’s Health Disparities/Equity Self-Directed Clinical Performance Improvement (PI) Activity submission to ABFM.

“What we found was that rent and transportation were the two biggest insecurities affecting our patients. People struggle with those. But our challenge became: Once we identify the issues, how do we address them?” Dr. Peri explained.

“We utilized a local taxi service for kids who needed to visit a children’s hospital. We raised funds and paid for that transportation. We made others aware of public transit availability. Sometimes the patient just needs to know what resources are available.”

For patients with money issues, Rosa Health Center connects them with local food banks and local non-profits. The center has even raised money for x-rays and other procedures for patients in dire financial need.

“We now have a resource person on staff who is very good. We sacrificed an exam room so she could have her own office and go through each family’s application. She lets them know what resources are available,” said Dr. Peri.

The screening tool’s success has created numerous opportunities for treating the whole patient. For example, staff is putting together a comprehensive and evolving list of resources statewide.

“This experience made me realize that social determinants of health can be the underlying reason for other problems a patient may be having. You never know what people are going through,” she said.

Rosa Health Center staff will soon build a more comprehensive screening tool in their Electronic Medical Records (EMR) so it can be accessed digitally instead of relying on paper handouts.

When Dr. Peri submitted these office developments to ABFM as a PI activity, she found the process simple and easy to follow. Using the MyABFM Portfolio, Dr. Peri shared how changes were implemented in her practice, the information her office collected and analyzed, and their plans for the future. “It was not difficult; the process was actually very smooth! I had a question at one point, and ABFM’s help desk was able to assist me right away,” she said.

Thank you to Dr. Peri and the staff at Rosa Health Center for putting health equity in action for their patients.