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This topic has 9 replies, 10 voices, and was last updated 3 years, 2 months ago by Juan Castro.

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    • > OPTION A: Take a snapshot of your current workflow and make note of what changes your organization can you make that are feasible to advance your SDoH and ES initiatives? If no workflow exists, refer to sample workflows in the PRAPARE Toolkit: Choose a workflow of your choice, then modify it to fit your organization’s needs and be sure to cite any sources. Feel free to post your workflow ideas, screenshots, or files here for others to see and comment on!

      > OPTION B: Pull a job description of a patient navigator, community health worker, care coordinator. See how you can modify that job description to advance your SDoH and enabling service initiatives? If no job description exists, sketch out an ideal position with a title and some responsibilities and duties of this position.

    • I do not have a snapshot, but here is our workflow.
      When the patient checks in for their appointment, if the patient is 18 years or older they are given the SDoH questionnaire to fill out. When the nurses calls the patient back to the room the nurses goes over the SDoH with the patient and the answers are then entered into the SDoH template in our NEXTGEN EHR. Depending on the answers, the patients are referred to our behavioral health counselors and/or the health educator/case manager.

    • I do not have those items.

    • Here’s an example care coordinator/patient navigator JD. I’ve added more language surrounding SDoH efforts throughout.

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    • This is my current role, I currently work to meet the SDOH needs and track data for SDOH.
      Position Summary:
      The Behavioral Health Care Manager (BHCM) is integrated within a primary care clinic to function as a member of the multi-disciplinary team to effectively manage referrals and coordination of care for patients, focus on social determinants of health and other needs that may impact health and wellbeing, provide patients and their supports with education, and helping patients navigate health and social services systems.

      Knowledge, Skills and Abilities:
      • Knowledge of:
      o Community resources and placement options for mental health, substance use disorders, and social determinants of health
      o Laws, policies, and regulations regarding mental health and substance use disorder treatments
      o Integrated care practices and procedures
      • Skills:
      o Scheduling/confirmation of behavioral health appointments within the primary care clinic
      o Coordinate and monitor specialty mental health and substance use disorder treatment referrals
      o Identify psychosocial barriers that would prevent adherence to referrals and impact overall health and facilitate referrals to available community resources and supports
      o Provide care management services to identified patients
      o Educate patient and supports on self-care and self-management to enhance self-efficacy
      o Facilitate access to educational materials for patients and supports
      o Assist with tracking data for grant reporting and quality improvement
      o Facilitate communication between primary care and specialty care providers as needed
      • Abilities:
      o Demonstrate strong organizational and computer competency
      o Provide clear and concise documentation
      o Promote community collaboration with Integrated Health Care services through participation in community forums (health fairs, task groups, multi-agency behavioral health initiatives and other community and agency functions)
      o Demonstrate cultural competency in serving diverse populations
      o Demonstrate practical application of case management knowledge
      o Track and update EHR based on outcomes of assessments, resources and referrals provided
      • Other duties as assigned

      Clinical Goals:
      • Improve patient adherence to healthcare goals
      • Support patient self-management of conditions and/or risk factors
      • Agent of behavioral change
      • Decrease over or under utilization of health services
      • Reduce health-risk behaviors and increase health enhancing behaviors
      • Monitor and improve population outcomes
      Quality Improvement:
      BHCs must understand and help enforce the meaning of quality improvement identified as the combined and unceasing efforts of everyone – healthcare professionals, patients, and their families, researchers, payers, planners and educators – to make the change that will lead to better patient outcomes, better system performance and better professional development (Batalden 2007). BHCs will demonstrate commitment to promoting TAPM as a medical home and incorporating the core components of a Patient Centered Medical Home into your position on a daily basis:
      1. Patient centered
      2. Comprehensive care
      3. Team based
      4. Coordinated
      5. Accessible
      6. Focusing on quality and safety

      System Wide Accountabilities:
      • Maintain a professional appearance
      • Demonstrate a positive attitude
      • Maintain a safe, clean and attractive environment
      • Communicate with compassion and courtesy
      • Anticipate needs of customers and others
      • Maintain patient privacy and confidentiality

    • BMS Health Coaches touch on SDOH tasks:


      The Health Coach will work cooperatively with nursing staff to achieve patient outcomes and goals. The primary responsibility includes implementing a collaborative process of data collection for the Health Home At-Risk project and Health Home eligibility, care planning, facilitation of population health management, coordination of care for patients on caseload, patient education, patient advocacy, and regular evaluation of patients on caseload.

      Uses registries to identify patients with newly diagnosed, undiagnosed or poorly controlled chronic conditions and schedules follow-up appointments.

      Conducts outreach to patients with overdue screenings or upcoming appointments.

      Performs intake and social data collection of patients with newly diagnosed or poorly controlled chronic conditions, screens for Health Home eligibility, and checks Health Home enrollment.

      Screens for behavioral health and substance use problems, including depression (PHQ), alcohol abuse (AUDIT), substance abuse (DAST) and smoking status.

      Reinforces education provided by PCP or nurse on management of the chronic disease, provides self-management tools, and reviews how to use those tools.

      Does post-visit review of next steps with patient. With the patient, establishes goals and creates a care plan. Works with patient to mitigate impacts of social factors on health and functional status, e.g. by arranging transportation for patients.

      Coordinates care, assists with referral management, and conducts between-visit monitoring & Outreach.

      Tracks and follows up on test results to ensure patient and caregiver take appropriate next steps as needed. Serves as primary care practice’s first point of contact during post discharge care transition from hospital or emergency department.

      Documents activities in EHR/GSI Health Dashboard. Works with Coordinator of Value Based Initiatives and practice’s performance improvement team. Assists in scheduling huddles and other internal team meetings.

    • We obtain SDOH at first Care Coordination appointment and then update every 6 months

    • For us, we will potentially need to adopt or modify the NACHC example workflow for Using Non-Clinical Staff Before or After the Clinical Visit. A local hospital has reached out to us about partnering to adopt their SDoH targeted referral system. If we pursue this opportunity, we may need to bring on additional staff to handle the collection of SDoH information from patients and to coordinate referrals to SDoH services.

      With regards to agency-wide expansion of SDoH collection, continued testing of various workflows and methods of how to collect and report SDoH information from patients will enlighten what positions and roles we will need to modify to increase collection and action on SDoH information. Because so many staff touch SDoH information in various capacities, one of our overarching future needs will be to create communication workflows and policies to facilitate the sharing of SDoH efforts and knowledge of various staff and departments.

    • See attached for a diagram of our care team which encompasses the CHW and Care Coordinator roles that are working towards addressing SDoH. We need to incorporate more SDoH language to this visual however!

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