KAISER PERMANENTE COLORADO S HUNGER SCREENING EFFORTS

Transcription

1 KAISER PERMANENTE COLORADO S HUNGER SCREENING EFFORTS A Case Study on Clinic- Community Integration to Address the Non- Medical Social Needs of Members

2 A. Introduction: Total Health and Clinic- Community Integration At Kaiser Permanente (KP), it is widely understood that addressing the non- medical social needs of members is critical to delivering on the organization s mission of providing high- quality, affordable care, and improving the health of KP members and communities. Through clinic- community integration (CCI) efforts, KP aims to integrate and coordinate KP clinical services with community based programs that address the non- medical social needs of members to support them in achieving Total Health - - a state of complete physical, mental and social well- being. Key elements of CCI efforts include: 1) the identification of an appropriate scope of services and network of providers to provide those services; 2) a referral system to facilitate the exchange of member information between clinical and community settings; and 3) innovative community engagement and outreach models. The following case study provides an example of how a clinic- community integration project is developed, implemented, and improved upon using data and performance improvement processes. B. KPCO Hunger Screening Overview Kaiser Permanente Colorado (KPCO) and Hunger Free Colorado, a community- based organization, collaborate to connect families and individuals to food and nutrition resources, and to create policy changes to address food insecurity. In 2011, KPCO began administering a hunger screening question during clinical visits, referring food insecure members to Hunger Free Colorado. Hunger Free Colorado outreached to those members to determine their eligibility for the Supplemental Nutrition Assistance Program (SNAP; formerly known as the food stamp program), refer them to Women, Infants, and Children (WIC) offices and food banks/pantries, and/or provide them with nutrition information. KPCO Departments Administering Hunger Screening OB/GYN (first prenatal visit) New Member Onboarding Pediatric Dietetics Asthma and Chronic Care Senior Care Care Transition Team Adolescent Health (well visits) Senior Home Health In progress: Pediatric Well Visits The program was first piloted in two pediatric clinics, and over the last three years has expanded to 10 departments and over 10 medical offices. Since 2012, approximately 1,839 members have been referred to Hunger Free Colorado, and 78% of them have been successfully outreached to by Hunger Free Colorado. Table 1 provides data regarding referrals of KPCO members to various resources since the effort was formalized in P age

3 Table 1: KPCO Hunger Screening Referral Report Performance Measures Total number of members referred to Hunger Free Colorado by KPCO 2014 (thru December) Total Number of members referred to SNAP by Hunger Free Colorado Number of SNAP applications submitted by Hunger Free Colorado online* N/A N/A Number of members referred to food pantries by Hunger Free Colorado Number of members referred to office of Women, Infants, and Children by Hunger Free Colorado Number of members that could not be reached by Hunger Free Colorado Data Unavailable Data Unavailable Data Unavailable ** * Submission of online application began in late summer An online application is completed by Hunger Free Colorado on behalf of the member once eligibility is determined via a phone conversation. **Current as of November Over the years, KPCO and Hunger Free Colorado have improved the collection and quality of referral data. As displayed in Table 1, some of the data captured by Hunger Free Colorado includes: the number of referrals received from KPCO, the number of referrals to various food resources, and SNAP eligibility. In order to examine the impact of the referrals on the health of members, however, additional data needs to be collected, such as the actual utilization of resources by KPCO members (e.g., successful use of food pantries, enrollment in WIC, etc.), and the health status of those KPCO members after utilizing resources. Evaluation planning efforts are currently underway, which will help determine what additional data can and should be collected. C. The Clinic Component Securing Provider Buy- in To integrate the hunger screening into clinical settings, a project team works with participating departments to demonstrate need and adopt a screening process that is tailored for each department. Key members of the project team include two KPCO physician champions passionate about addressing hunger and key staff from KPCO Community Benefit and Hunger Free Colorado. Demonstrating to providers that food insecurity is a problem among KPCO members is a key first step. In 2011, when one of the physician champions originally proposed the idea of integrating a hunger screening question into pediatrics, she was met with some resistance. Though there was awareness that 2 P age

4 food insecurity was an issue in the state of Colorado, there was a belief within the organization that hunger was not an issue experienced by KPCO members. To address this, the project team surveyed families using two validated hunger screening questions in two pediatric clinics Smoky Hill and Westminster to gather data on the prevalence of food insecurity. Not only did the lower- income region of Westminster report 16% of members being food insecure, but the middle class community of Smoky Hill reported 12% of members being food insecure, a prevalence higher than expected and similar to that of the low- income community. This data demonstrated to providers that hunger was an issue among both low and middle- income KPCO members. The adoption of the hunger screening by other departments and medical offices has followed a similar process. The project team engages the care delivery teams, tailoring each presentation to include relevant prevalence data, and explaining how food insecurity impacts members cared for by those care teams/departments. Integrating Hunger Screening into Clinical Workflow Once the outreach team garners initial support from providers, the project team supports the care team in determining where in their care delivery workflow the hunger screening should be incorporated. To maximize ownership by each department, the project team encourages the care team to integrate the hunger screening in a way that minimizes disruption of existing systems and processes and maximizes alignment with the structure and culture of that team. Adults and Parents: Customized Screening Questions Depending on the care team/department, the screening is typically administered via a questionnaire, during phone consultations, or during an in- person visit. For example, in OB/GYN, the physician champion worked with an obstetrician to take advantage of a real- time opportunity to revise their entire questionnaire to include more social and behavioral assessments, including the hunger screening. In pediatric dietetics, providers worked with the physician champion to integrate a hunger screening question into their smart set 1. In both cases, providers reported having minimal difficulty integrating the screening into their workflow. Despite success in implementing the hunger screening in multiple departments, there is continued skepticism regarding more universal food insecurity screening, as addressing social concerns is not traditionally part of provider trainings, which decreases their likelihood of considering such issues in their clinical practice. Additionally, many front- line staff have reported discomfort in asking the screening question because of the stigma that is associated with food insecurity. The project team continues to work with providers to increase awareness about hunger, as well as promote the development of skills, such as motivational interviewing, that can help providers feel more comfortable discussing social, non- medical needs with members. Seniors: Within the past 3 months we worried whether our food would run out before we had the money to buy more Within the past 3 months the food we bought just didn t last and we didn t have money to get more Medication and healthy foods can be expensive, but both are important; would you like information on resources that can help stretch your budget? 1 A virtual checklist of questions/prompts and notes in electronic medical records used to guide and document provider- patient interactions. 3 P age

5 Evolution of the Referral Process Over the years, KPCO and Hunger Free Colorado have collaborated closely to create a maximally efficient referral process. Evolution of the referral process has emphasized streamlining and greater use of technology. During the initial pilot in 2011, when a member tested positive, providers referred them to Hunger Free Colorado by providing them with a card that contained the organization s hotline number, which members were expected to contact on their own. The pediatric team referred a large number of members, but Hunger Free Colorado reported that less than 5 percent of KPCO referrals were calling the hotline. To address this, the project team next developed a referral form for providers to submit via fax or electronically to Hunger Free Colorado. Within the member s electronic medical record, providers selected the hunger referral form, which was prepopulated with the member s contact information. Members either signed the form or verbally agreed to be referred to Hunger Free Colorado for follow- up outreach. In some departments, hand- written referrals were faxed to Hunger Free Colorado. A major challenge with this process was the heavy reliance on providers to submit referral forms, given the limited time available during patient visits. In early 2014, the referral process changed to include KP Community Specialists, whose role is to connect members with resources for non- medical needs, including housing, dental care, transportation, loss of health insurance, and financial assistance. When a member tests positive for food insecurity, they are referred directly to a Community Specialist who completes the electronic referral form with the patients and submits it to Hunger Free Colorado. Community Specialists also screen these members for other non- medical needs. D. The Community Component Hunger Free Colorado was launched in 2009 from a merger of the Colorado Anti- Hunger Network and the Colorado Food Bank Association, with key funding support from The Denver Foundation and Kaiser Permanente. Hunger Free Colorado aims to bring a unified, statewide voice to the issue and solutions surrounding hunger, with a goal of ensuring that all Coloradans have access to affordable, nutritious food. The organization has two food assistance navigators that staff the statewide, bilingual hotline, which serves as a one- stop free resource to connect all Coloradans to food resources. These two navigators are responsible for all of the inbound and outbound calls that includes both KPCO and non- KPCO referrals. Hunger Free Colorado currently has more than 1,600 community organizations, county human service agencies and other nutrition resources in their statewide database, with 177 added in The Hunger Free Hotline has assisted 15,375 households since its launch in When Hunger Free Colorado receives a referral from a KPCO Community Specialist, they are notified in real- time via fax. The food assistance navigators call each member, conduct an intake assessment to determine eligibility for food assistance, and complete an application for federal nutrition programs on the member s behalf if they qualify. Members are also referred to other resources including food banks, food pantries or WIC. For each resource or activity that a member is referred to, Hunger Free Colorado 4 P age

6 conducts up to 3 follow- up calls to support the members in successfully accessing those resources. When Hunger Free Colorado submits an application for federal nutrition programs on behalf of the member, a copy of the application is mailed to the member and a follow- up call is made within 2 weeks. E. Information Exchange Every month, Hunger Free Colorado provides KPCO Community Benefit staff with a report that includes the number of people referred, what resources they have been referred to (e.g. food pantry, food bank), and the number of members eligible for SNAP and Medicaid (see Table 1). Community Benefit staff shares this information with the leads of participating departments. Some, though not all, frontline providers are provided with this information by their department leads. Over time, the data collected for purposes of program improvement has evolved. For example, the project staff recently worked with Hunger Free Colorado to update the referral forms to include the name of the referring provider. Hunger Free Colorado now includes this information in their referral reports, enabling KPCO to identify which department may need more support to increase their referral numbers. An ongoing challenge with data collection is the ability to systematically track referrals within KPCO. Given that each department captures screening data differently, and that the screening data may or may not be entered into a member s electronic medical record 2, currently there is no efficient way to query for positive results within or across departments. F. Communication and Continuous Improvement As a way to share best practices and to surface and address challenges, the project team convenes a quarterly phone meeting that is open to all providers participating in hunger screening. During these calls, the project team, Hunger Free Colorado staff, and KPCO providers are encouraged to identify processes that are working well and ways to improve the referral and accompanying outreach. For example, on one call, a provider reported that a member was referred to a food pantry that was no longer open. Hunger Free Colorado staff immediately contacted the member to offer other resources, in addition to implementing a process to more frequently update their list of resources. The ability to directly communicate the problem to Hunger Free Colorado, and Hunger Free Colorado s quick and transparent response renewed the provider s trust and participation in the hunger screening effort. In addition to these quarterly meetings, the project team also meets on a monthly basis with Hunger Free Colorado to discuss the partnership between the two organizations. The project team checks in with key staff at Hunger Free Colorado by phone or in a face- to- face meeting to discuss policy issues. This allows for a more private venue to address any critical issues that may not be relevant or appropriate for the quarterly calls. 2 Current ICD- 10 codes do not include food insecurity as a medical classification. 5 P age

7 G. Support of Relevant Policy, Systems and Environmental Changes The fullest expression of CCI includes not only connecting members with resources, or shared care arrangements with quality community- based resources and providers, but also supporting policy, system and environmental changes in the broader community. KPCO has leveraged multiple assets of the organization to drive policy change and establish community infrastructure that has enabled the successful hunger screening and outreach efforts described above. Since 2011, Colorado has improved its ranking from 50th (i.e. the lowest participation) in the country to 45th for SNAP participation. During that time, members of the KPCO project team have actively participated on an anti- hunger coalition focused on implementing statewide policies to increase access to federal nutrition programs. Also, KPCO has been involved in state level policy- making, with clinicians talking about the negative impacts of hunger on the health of KP members to make the point that lawmakers can improve health by supporting the passage of appropriate public policies. For example, in early 2014, a Kaiser Permanente physician provided formal testimony in favor of the Breakfast After the Bell Nutrition Program that addresses child hunger by requiring schools to serve a nutritious breakfast if 80 percent or more of the student body is eligible for free or reduced- price lunch. That legislation was subsequently approved on May 15, Additionally, as a funder, KPCO has provided numerous grant funds over the years to help create and grow Hunger Free Colorado and their statewide hunger hotline that serves all Coloradans in need of resources to address hunger. These community- level changes are an important complement to the clinical screening efforts taking place within KPCO. Without a strong community- based partner such as Hunger Free Colorado, and without state policies that reduce barriers to enrollment in federal nutrition programs, KPCO s efforts to screen and refer members to food resources would be much less effective or perhaps impossible. H. Initial Spread Outside of KP Colorado Community- based organizations in Colorado as well as other KP regions have demonstrated interest in integrating hunger screening into their care settings, and KPCO has served as a consultant to many of the organizations interested in spreading this work. Colorado Community Partners A number of organizations in Colorado have reached out to KPCO to learn about the hunger screening tool and the process for integrating the tool into clinical care settings. KPCO has shared its expertise with various organizations, including Denver Health Pediatrics, State Visiting Nurse Association, the Colorado Association of School Nurses, pediatric obesity clinics in underserved communities, and Routt County Hospitals and Clinics. KP Northwest Region In September 2014, KP Northwest, with consultative support from KPCO, integrated a hunger screening question into pediatric well- child questionnaire with a explicit focus on connecting members with community resources. When a member screens positive for food insecurity, the clinician provides the member with an after- visit summary that includes a list of community- based food resources that was created by the Oregon Food Bank, a community- based organization. The list of resources provided to a patient is geographically specific and available in multiple languages. 6 P age

8 For several years, KP Northwest Community Benefit staff have participated on the steering committee of the Childhood Hunger Coalition (CHC), a program of The Oregon Food Bank dedicated to providing ongoing education and outreach tools for clinicians in an effort to reduce childhood hunger and improve the health of children and families. 3 Though the CHC was working with partners to integrate hunger screenings into healthcare settings, there was no capacity to strategically scale this work until early 2014 when The Oregon Food Bank received funding to hire a staff person to do the necessary outreach and provide technical assistance to healthcare providers. Meanwhile, at KP Northwest, with the expansion of Medicaid and the projected increase of low- income members, Community Benefit staff became increasingly interested in screening for food insecurity in order to improve health outcomes. Knowing that the increased capacity at CHC would be a resource to leverage, CB staff moved the program forward with the leadership and championship of the region s Medicaid leader, who was also a practicing pediatrician. Similar to the Colorado experience, this physician was able to secure buy- in from other pediatricians to implement the screening, which did not require any significant workflow changes in the clinic. The hunger screening team hopes to use the experience in the pediatric setting to expand into other departments, such as OB/GYN. In addition, they are exploring how to effectively track and follow up with patients who have received the list of resources. KP Mid- Atlantic States Region Currently the KP Mid- Atlantic States (MAS) region is planning an effort that involves screening for food insecurity in two safety net clinics that KP MAS works with closely. Staff anticipate that patients who screen positive for food insecurity will be referred to a community- based organization specializing in anti- hunger efforts for information about federal nutrition programs, food banks/pantries and other available resources. I. Lessons Learned A number of lessons learned from KPCO s hunger screening efforts are broadly applicable to clinic- community integration efforts. 1. Passionate and persistent physicians/provider champions are key Physician champions are critical for generating support from the provider community. To implement the screening, two physicians with a passion for addressing hunger were actively engaged in the outreach to different departments and the development of the screening tools. The physician champions were able to leverage their relationships with other providers to set up initial meetings, and also played lead roles in addressing ongoing concerns by serving as subject matter experts and consultants. Moreover, a physician champion who has implemented the program in her own clinical practice can speak first- hand about her successes and challenges, which inspires confidence in other providers. 3 The Coalition is a program of Oregon Food Bank led by a steering committee of representatives from OSU Extension Service, Oregon Health & Science University, Oregon Hunger Task Force, Oregon WIC, Kaiser Permanente and Oregon Food Bank. 7 P age

9 2. Active championship, case- making, and problem- solving is required during implementation Culture change is rarely achieved by sharing information and expecting teams to be inspired to change entrenched care delivery processes and systems. In order to obtain buy- in from the providers, the project team had to prove that the screening was worthwhile and addressed a critical unmet need. The project team dedicated the initial months of the effort to collecting data on hunger prevalence in order to demonstrate that some KPCO members indeed experienced food insecurity. During implementation, the project team provided trainings on how to administer the screening question and served as an on- going resource for problem- solving and to drive performance improvement. 3. Dissemination may still require a tailored approach for each department or team A tailored approach can be necessary because clinical teams care for different populations (e.g., children, adults, seniors, etc.) and are more receptive to customized messaging and data highlighting how the health of their target population will be impacted. Furthermore, each department and clinic has its own care delivery process/workflow that any new intervention needs to fit within; regional clinical leaders are not able to develop a one- size- fits- all intervention because each clinic has autonomy over its workflow. Though the customization to meet the needs of each care team is likely a key factor in the successful adoption of hunger screening in various parts of KPCO, it can also be a barrier for future expansion because of the high level of effort required by the project staff to support customization by each care team. 4. Partnering with high- capacity community organizations with mission and goal alignment is critical to success Working with a community- based organization who is seeking the same outcomes as KP is a fundamental element of the effort s success. For KPCO, Hunger Free Colorado is a willing and capable referral and outreach partner for KPCO s hunger screening efforts. At the same time, they have sufficient capacity in their organization to provide referrals for other organizations as well as pursue advocacy efforts to improve food security through policy and systems changes in their state (in which they regard KPCO as an important partner). These complementary activities and capabilities of Hunger Free Colorado indicate their high level of functioning and organizational sustainability. 5. Integration of community partner data with member medical records is needed in order to fully maximize and understand the impact of non- clinical resources on health One of the motivations for connecting members to non- medical social resources is the hypothesis that doing so will lead to overall improved health outcomes since the lack of those resources can exacerbate existing illness or lead to poor health status. Integration of community partner data with member medical records is important for two reasons. First, it facilitates provider follow up on member referrals to community resources. For example, KPCO does not have a way of systematically indicating in a medical record that a member has been referred to Hunger Free Colorado, making it difficult for the member s clinician to inquire about the use or impact of food resources. Second, it facilitates research and evaluation regarding the link between successful referral and access to non- medical resources and the resulting impact on members health and utilization of care. The outcomes of such studies could help improve 8 P age

10 referral processes, and/or identify specific resources that have greatest impact on health outcomes. J. Acknowledgements Thank you to these individuals who shared their experiences and insights on implementing hunger screening in KPCO: Michele Gilson Stephanie Hancock Carmen Martin Maryann McLendon Sandy Stenmark, MD Sarah VanScoy, MD Jannifer Yanez KPCO - Registered Pediatric Dietician KPCO - Registered Pediatric Dietician KPCO Community Benefit - Senior Community Health Specialist Hunger Free Colorado Food Assistance Program Lead KPCO - Physician Champion KPCO - Physician Champion KPCO- Registered Pediatric Dietician 9 P age