THE IMPOSSIBLE BECOMES POSSIBLE. WHY THE CHALLENGE???

Transcription

1 THE IMPOSSIBLE BECOMES POSSIBLE. WHY THE CHALLENGE??? SDOH INTEGRATION INTO OUR HEALTH CENTERS Karen L. McGlinn, CEO Share Our Selves Corporation Costa Mesa, California THE AUDACITY OF MISSION SOS MISSION STATEMENT We are servants who provide care and assistance to those in need and act as advocates for systemic change. 1

2 GLOBAL CASE STUDY GLOBAL CASE STUDY 2

3 GLOBAL CASE STUDY PERSONALIZING THE PLATFORM SOS was founded in 1970 and understood the principles of SDOH before it was given a name and identified as a model. 3

4 EVOLUTION OF SOS Established Medical Clinic Established Dental Clinic Established Integrated Behavioral Health Established Clinical Pharmacy Services Health Mobile Unit SOS founded as a social service agency for low income, migrant, homeless Began establishing other clinics in areas of need FQHC with Health Care for the Homeless Provider Designation SOS Center of Care for the Homeless THE ROAD LESS TRAVELED Transformation Innovation Facilities of the Future 4

5 THE SOS EXPERIENCE NEIGHBORHOOD & BUILT ENVIRONMENT Transportation Utility Assistance SOCIAL AND COMMUNITY CONTEXT ID Assistance Legal Aid California Lifeline Holiday Support Programs EDUCATION Care Navigation Back to School Program Health Education Financial Management Classes Cal-Fresh Linkages Shelter Referrals ECONOMIC STABILITY Financial Assistance Rental Assistance Food Pantry Clothing HEALTH & HEALTH CARE Eligibility Assistance Case Management Clinical Linkages OUR RECIPE STAYING HEALTHY ASSESSMENT Patient intake evaluation ELECTRONIC HEALTH RECORD Patient input into SOS database MORNING HUDDLE Opportunity to discuss upcoming patient needs PATIENT Walk-In Referral Hospital Discharge Insurance Assignment MULTI DISCIPLINARY TEAM Doctor, Social Services, Behavioral Health, Public Health Nurse PROVIDER APPOINTMENT Healthcare visit SOCIAL SERVICES Case Management Officer of the Day 5

6 THE SECRET INGREDIENTS Share Our Selves Staff and Board Members Relationships with Patients BRINGING STAKEHOLDERS ALONG UNUSUAL SUSPECTS Police Departments HUD Housing Partners Private Donors Corporate Donors School Districts City Entities OC Healthcare Agency Local Hospitals Community Based Organizations Faith Based Organizations 6

7 CALL TO ACTION! STAFF PARTNERSHIPS FACILITIES FUNDING STREAMS AUDACITY TO THINK BIG CONTACT INFO Share Our Selves 1550 Superior Ave. Costa Mesa, Ca (949) shareourselves.org Karen L. McGlinn Chief Executive Officer (949)

8 PROMISING MODELS TO ASSESS SOCIAL DETERMINANTS OF HEALTH OF PATIENTS IN CHCS La Clinica s Journey for Health Equity Viola Lujan Director of Business & Community Relations La Clinica de La Raza, Inc. 8

9 Agenda Brief history of La Clinica Health equity NACHC pilot Workflows Data findings Future plans Organizational history with SDH History and Roots Vision-Mission-Principals-Strategic Plan CHC s Health Equity Future Pay for Performance & Alternative Payments Patients and Communities 9

10 Why SDH? Equity Justice - Right Thing to Do Equality vs. Equity vs. Reality Why SDH? Behaviors and Environment Affect Health Outcomes 10

11 La Clinica s SDH Sub-Committee Agency wide Continuous Quality Improvement (CQI) Committee Annual special initiative to promote QI methods and goals throughout the agency SDH Sub-Committee Diverse representation Leadership support Awareness and advocacy NACHC PRAPARE Pilot Funding from Blue Shield Foundation to roll out PRAPARE tool to other CHCs in California and invited representatives from each consortium Goal is to collect at least 400 surveys Started data collection in April 2017 PRAPARE template in NextGen 11

12 Administering PRAPARE in non-clinical settings (pros and cons) Who Administers PRAPARE No Wrong Door approach Community Health Educators Patient navigators Nurse health coaches Population of Focus Re-entry population Uninsured patients General population (ACA enrollments) High Risk-High Utilizers Emergency room utilizers Initial Data Findings (n=406) Are you worried about losing your housing? I choose not to answer, 2% Skipped question, 4% Yes - patients with unstable housing, 25% No - patients with stable housing, 68% 12

13 Initial Data Findings (n=406) Stress is when someone feels tense, nervous, anxious or can t sleep at night because their mind is troubled. How stressed are you? 26.60% 20.20% 18% 15.30% 11.10% 5.20% 3.70% Not at all A little bit Somewhat Quite a bit Very much I choose not to answer this question Skipped question Initial Data Findings (n=406) In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? (Check all that apply) 58.10% 18.20% 11.60% 14.50% 9.40% 11.80% 1% 4.90% 0.25% 4.70% Food Clothing Utilities Child care Medicine or any health care (Medical, Dental, Mental Health, Vision) Phone Other I choose not to answer this question No Skipped question 13

14 1 SIMPLE WIN with Food Insecurity Need Identified Food insecurity identified through PRAPARE CalFresh Enrollment Patient not aware Complicated process Underutilized resource Prevalent issue in our Communities Family Impact $270 increased funds for family per month $3,240 supplemental income per year More nutritious food on the table Data Challenges At La Clinica, PRAPARE is administered with paper form One staff member collects surveys and inputs data into EHR, which is not sustainable Need for multiple data collection options Need a better system to pull PRAPARE report from EHR 14

15 Future Plans Develop an internal community resource directory for all staff to access and use Continue to build partnerships Find funding to sustain SDH data collection Collect data on enabling services Review findings with the NACHC learning community Thank you! Viola Lujan 15

16 A South L.A. Case Study Screening for and responding to SDOH Lyndee Knox, PhD LA Net Disclosure I/my company has a financial interest in the following product that will be discussed today: PatientToc 16

17 A South L.A. Case Study Screening for and responding to SDOH Lyndee Knox, PhD LA Net What we have is death by 1,000 pilots. Loel Solomon, Vice President of Community Health, Kaiser Permanente 17

18 Florence Western Patients: 4,000+ Clinicians: PA (1 FTE) MD (1.5 FTE) EHR: Office Ally Demographics: Black 60% Latino 35% White or other 5% Payer mix: MediCal 40% Medicare 40% Other 20% The Journey 18

19 Why do this? Health SDOH are responsible for as much as 50% of health outcomes

20 Also. Value Based Payment "There is mounting evidence to suggest that SDH influence health outcomes more than medical care.." AAFP Goals Use SDOH information to increase likelihood of better outcomes & improve performance on quality metrics tied to revenue Blood pressure (medication adherence) Ratings on CAHPS (patient experience) Patient s active engagement in their own care 20

21 Screening approaches considered Universal Targeted Why universal screening? "You can t tell by looking at a patient if they are struggling to put food on the table or pay rent. Alicia Cohen, M.D., M.Sc. 21

22 Also Simpler everyone gets an SDOH screener Selecting a screener NACHC PRAPARE Health Begins SDOH screener WHO SDOH items A mix of several (NAM 12 social & behavioral factors for EHRs) 22

23 Why a mix of screeners? Wanted items that supported meaningful action Wanted to include loneliness as a determinant Some items What is your First Name? What is your Middle Name or Initial? What is your Last Name? What is your date of birth? What is your Gender? What is your current marital status? What is your zip code? What is your racial group? What is your ethnic group? What is the highest level of school you have completed? What is your employment status? Diet and exercise On average, how many days per week do you engage in moderate to strenuous exercise (like walking fast, running, jobbing, dancing, swimming, biking or other activities that cause a light or heavy sweat)? On average, how many minutes do you engage in exercise at this level? How many pieces of fruit, of any sort, do you eat on a typical day? How many portions of vegetables, excluding potatoes, do you eat on a typical day? Loneliness/Social connection How often do you feel that you lack companionship? How often do you feel left out? How often do you feel isolated from others? Financial stress Do you ever have problems making ends meet at the end of the month? How hard is it for you to pay for the very basics like food, housing, medical care, and heating? In the past 12 months, has the electric, gas or water company threatened to cut off services in your home? Housing insecurity What is your housing situation today? Think about the place you live. Do you have problems with any of the following (check all that apply) Food insecurity Which of the following describes the amount of food your household has to eat? Within the past 12 months we worried that our food would run out before we got money to buy more. Is this statement often, sometimes or never true for your household? Within the past 12 months the food we bought just didn't last and we did not have money to get more. Is this statement often, sometimes or never true for your household? In the last 12 months, did you ever not eat for a whole day because there wasn't enough money for food? In the last 4 weeks, did you ever not eat for a whole day because there wasn't enough money for food? Transportation Concerns In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living (check all that apply) Safety Concerns Do you have any concerns about safety in your neighborhood? How often does anyone, including family, physically hurt you? How often does anyone, including family, insult you or talk down to you? Do you feel this kind of stress these days? Depression In the past 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things Feeling down, depressed or hopeless Substance abuse AUDIT C 23

24 Method of conducting screenings Old fashioned pen & paper Entry into EHR (interview by CMA) Custom HIT solution Why custom solution? Old fashioned pen and paper Entry into EHR (interview) Custom HIT solution Low-literacy + paper-pushing & time EHR not ready + staff time Pushes work to the patient (reduced impact on staff) Reads questions out loud in different languages (solved literacy/lep) Automatically connects patients to services via ed video, text, , print (solved no social worker/cc) 24

25 Actions following screening Info TRANSMITTED TO EHR for later use PCP views and uses DURING VISIT/EXAM System AUTOMATICALLY introduces & connects patient to local services based on their responses (via video then text/print) Date of Birth: 12/1/1942 Date of Report: 10/6/2017 Language administered in: Advanced Social Determinants Question What is your race? Mark one or more. Are you of Hispanic or Latino origin or descent? What is the highest grade or level of school that you have completed? What Is your employment status? Please tell us about your other employment status On average, how many days per week do you engage in moderate to strenuous exercise (like walking fast, running, jogging, dancing, swimming, biking or other activities that cause a light or heavy sweat)? On average, how many minutes do you engage in exercise at this level? How many pieces of fruit, of any sort, do you eat on a typical day? How many portions of vegetables, excluding potatoes, do you eat on a typical day? How often do you feel that you lack companionship? How often do you feel left out? How often do you feel isolated from others? Do you ever have problems making ends meet at the end of the month? How hard is it for you to pay for the very basics like food, housing, medical care, and heating? What is your housing situation today? Answers Black or African American No High school graduate or GED Retired 0 times per week Do you feel this kind of stress these days? 1 piece 2 portions Hardly ever Hardly ever Hardly ever Yes Somewhat hard I have housing Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner? having little interest or pleasure in doing things? feeling down, depressed, or hopeless? You indicated you have had some concerns about access to healthy food and / or feeling lonely. Would you be interested in learning about some great local resources to maybe able help you. Would you like PatientToc to send this information to you by text or ? What is your cell phone number? What is your address? No A little bit Not at all Not at all 25

26 Workflow Use of SDOH information (4 min) Patient checksin at counter Greeter checks status/shows pt to assessment tablet Greeter enters patient s MRN & selects language Patient enters name, answers 20 behavioral & SDOH questions Patient called back for visit Patient receives information via text/ /print Patient requests more information/connection to services Patient views SDOH or health ed video Viewed by clinician on EHR/tablet/paper Alert to plan/chw Data transmitted to EHR/ server Outcomes so far. Screened (adults) N=376 Food insecure 23% Not eat for a whole day in past 4 weeks 11%*** Losing/lost housing 17% Loneliness/social disconnection 11% Safety concerns 25% Toxic stress 20% Others. Patient automatically intro/connected to services 41%* via Text 81%** 26

27 Next steps EXPAND automated connections to services (evaluate impact) BETTER INTEGRATE use of SDOH INFORMATION into healthcare visit Training/capacity building resources: Health Begins Health Leads TRANSMIT SDOH INFO REAL-TIME to local HEALTH PLAN (eventually generate outreach) 4 OFFER TELE-DETERMINANT VISITS Thank you 27