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This topic has 19 replies, 17 voices, and was last updated 2 years, 8 months ago by Javier E. Alvarado.

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    • For Week 3, please select 1 of 3 questions below and reply with your response by: Tuesday, February 26th at 11:59 pm ET. (Please note: if you’re feeling like an overachiever, feel free to answer more than one question):

      1) What is your organization currently doing, planning to do, or needing, to train staff on Social Determinants of Health (SDoH) data?
      (Examples include educating staff on the importance of the social determinants, how it aligns with Patient-Centered Medical Home efforts, how to collect those determinants using the specific EHR system, and how to connect patients to available resources to meet the needs identified.)

      2) Let’s assume that you’ve successfully implemented standardized data collection systems for SDoH and Enabling Services interventions. What challenges do you perceive in using that data to achieve value-based payment reform, and who are the best staff persons (operations, policy, etc.) in your organization to advocate for that kind of change?

      3) What is your city, county, or state currently doing, planning to do, or needing, to implement value-based payment reform?
      (Examples include policy advocacy for enhanced reimbursement and participation in SDoH-related pilot initiatives.)

      • Not informed too much on these topics as I’m a call center agent.

        • Hi Ely! Thanks for your candid response. I’m curious to know how call center agents, like yourself, can be incorporated into SDoH work. When I think call center agents, I automatically think of patient advocate or patient representative because your role has the potential to connect patients or new patients with the right person, service, or resource. Perhaps being aware of SDoH initiatives at your health center or organization is enough to make sure you’re communicating potential services that someone is curious about. Any thoughts?

      • For the second question, the biggest challenges for La Clinica around this area is entering/coding the SDoH work that we’re doing in a manner that is reportable as part of claims work. We have built templates and databases to hold SDoH information but these spaces are not necessarily where claims information gets pulled from. We can create separate reports that track this information and send those to our health plan partners but that is time and staff intensive, especially as we work out kinks in the reports as we pilot and create them.

        Tied to staff training, we are working on how to educate staff on how to use enabling codes to track the SDoH work that we are already conducting. A challenge for us will be how to track and report if patients are being referred for SDoH services and where that will be tracked. If this data is going to be tracked in our EHR system, then we will need to expand access to our EHR system to SDoH staff that has historically not had access to our EHR.

        The best staff to address these issues is going to be our existing SDoH Committee and key stakeholders from billing and clinical operations that can work to modify existing workflows to best address these issues. The committee space will be the best space to work out potential conflicts and trouble shoot workflows.

    • 3) What is your city, county, or state currently doing, planning to do, or needing, to implement value-based payment reform?
      (Examples include policy advocacy for enhanced reimbursement and participation in SDoH-related pilot initiatives.)

      NC is moving right along with Medicaid Transformation and all organizations accepting Medicaid are mandated to be collecting SDoH information (as outlined by the state) by the end of this year. Our region “goes live” in November of this year!

      • Thanks for sharing your state’s update, Amy! I’ll be keeping an eye out on NC and hope the go-live goes smoothly in November! And I’m sure my fellow NCA Faculty and your fellow participants would love to keep in touch even after this learning collaborative ends. Looking forward!

    • 1) What is your organization currently doing, planning to do, or needing, to train staff on Social Determinants of Health (SDoH) data?
      (Examples include educating staff on the importance of the social determinants, how it aligns with Patient-Centered Medical Home efforts, how to collect those determinants using the specific EHR system, and how to connect patients to available resources to meet the needs identified.)
      ANSWER: Right now our organization is screening all of our patients 18 and over with the SDoh form. Depending on the patient’s answers we then refer to our Health educator/case manager and/or our behavioral health counselor.

      • Hi Angie,

        Thanks so much for sharing what your organization is currently doing. It’s great to hear that you’re screening all patients 18 and over, and it sounds like you have an interdisciplinary team involved for referrals. We’d love to hear how you have trained your staff to conduct these screenings, when these trainings have taken place (e.g., at the beginning of employment, ongoing trainings), and how you have been able to achieve buy-in from your leadership.

        Thanks, again!
        Joe

    • 1) What is your organization currently doing, planning to do, or needing, to train staff on Social Determinants of Health (SDoH) data?
      (Examples include educating staff on the importance of the social determinants, how it aligns with Patient-Centered Medical Home efforts, how to collect those determinants using the specific EHR system, and how to connect patients to available resources to meet the needs identified.)

      We have several different outlets for staff and patients at our clinic. We have Eligibility Specialist and Patient Advocates we also offer same day apt with all providers and Behavioral Health. We are using PRAPARE and staff is train to pick up on needs expressed.
      I do feel out city and state could help more with providing more transportation choices at a cheaper rate and shelter for those waiting on transportation. We have a program for discounted Medical care that covers Physical Therapy, Behavioral Health, Pediatrics and Adult Medical, also Health Education programs.

      • Hi Amanda,

        Thanks so much for sharing! It’s great to hear that you’re using PRAPARE, and that your staff are trained to “pick up on needs expressed”. The latter statement reminds me of trainings like “empathic inquiry” or other conversational approaches (e.g., motivational interviewing). Has your organization utilized these types of trainings?

        And we couldn’t agree with you more on how cities and states can be more helpful in providing better transportation choices, as this impacts access to care for vulnerable populations. From a policy perspective, do you think there might be an opportunity for your organization to present data on your patients’ needs to your city and/or state government officials?

        Thanks, again!
        Joe

    • 1. Currently we are incorporating SDOH into our onboarding process as to familiarize new staff on our community prevention mindset. We have an onboarding packet and video that we use during training and we also incorporated the video with a quiz into our online all-staff training system. We are constantly surveying patients and utilizing different departments to do so in order to help in their individual understanding of why we do this.

    • 1) What is your organization currently doing, planning to do, or needing, to train staff on Social Determinants of Health (SDoH) data?
      Locating information, training opportunities and offering any assistance to the HC’s for SDoH
      2) Let’s assume that you’ve successfully implemented standardized data collection systems for SDoH and Enabling Services interventions. What challenges do you perceive in using that data to achieve value-based payment reform, and who are the best staff persons (operations, policy, etc.) in your organization to advocate for that kind of change? How to incorporate it in daily processes where it becomes a habit for staff.
      3) What is your city, county, or state currently doing, planning to do, or needing, to implement value-based payment reform?
      In Arkansas at the CHCA, we are looking for more educational opportunities and on what they can do with this information. How it can help them improve the health of their patients. Hopefully we can add site visits as well.

    • #1.
      We are focusing on surveys and descriptive research through direct communication with our clients. The Social Service Team listens to what the patient is saying as well as what they are not saying. Making sure that they understand the biopsychosocial all are present and work together. We can then document our findings in our EHR system to generate specific reports. So with that we have in place several departments within Social service to deal with behavior, housing, economics and health.

    • 3) What is your city, county, or state currently doing, planning to do, or needing, to implement value-based payment reform?
      (Examples include policy advocacy for enhanced reimbursement and participation in SDoH-related pilot initiatives.)

      Our region here in PA currently is involved in a Patient Centered Medical Home learning network with our MCO payors. We have been recently been requested by the state to start addressing SDoH in these meetings as well. There are reimbursement models for those involved in these efforts.

    • We are looking into training our behavioral health case worker and one of our nurses to collect the social determinates o f health. We are looking at the PRAPARE and a form that in already in our EHR. We think this could be especially helpful in working with patients with diabetes on figuring out barriers to their care.

    • 1. Offer and provide education to all health centers about the importance of SDOH and how it aligns with PCMH and QI activities around managing population health. In addition to this, a tool is provided to participating health centers to help manage SDOH data in a meaningful way (aligned w/ PRAPARE). We plan to continue this effort to help health centers better manage their populations.

    • 1) What is your organization currently doing, planning to do, or needing, to train staff on Social Determinants of Health (SDoH) data?
      (Examples include educating staff on the importance of the social determinants, how it aligns with Patient-Centered Medical Home efforts, how to collect those determinants using the specific EHR system, and how to connect patients to available resources to meet the needs identified.)
      Currently, WRHS has just started to screen patients on SDOH. 2/18/19 was the first day we started screening all patients both adult and pediatric. Once we start to obtain more data I think the next step is to look at the most prevalent needs are for our patients and discuss what options we have to increase these services; either on site or with a community partner. I think that once we have more data it can also be used to compare it to their medical diagnosis/condition to determine what SDOH factors that impact their health and if there are trends that can help our staff find better ways to
      improve the patients health outcomes. I think that the SDOH data is no surprise to our community resource and case management department, as this the area of service that they work in each day. I am hopeful that this data will enhance the conversations we have with other providers, staff, partners, and state officials regarding the magnitude of need our patients have.
      In discussions I have had with both staff and community partners a lot of people think that these SDOH needs are limited to the Medicaid or even Medicare population and that the commercially insured patients likely do not have these needs due to their income. In speaking with other health centers who are doing this work in Rhode Island staff has been surprised at the level of need for the commercial patients as well.
      Training has begun on how to input the data into the template and who to refer to based on those answers. Moving forward, I think there will need to be training on how looking at this data can enhance patient care, what other referrals could be made, and how staff can collaborate throughout the facility to provide the most appropriate services to all our patients.

    • Our providers and staff are no strangers to the Social Determinants of Health. However, our clinic has not implemented an organization-wide screening tool to collect SDoH data. With that said, we’ve been collecting and reporting SDoH data for quite some time. Our front desk staff collects demographic data that we present and discuss during our monthly meetings. We use this data to determine staffing needs and ensure that our team is representative of the community we serve. The front desk staff is also tasked with calling patients who no-show to appointments to determine barriers to access (e.g. transportation). Our pediatric providers are great with performing weight/physical activity/nutrition counseling and referring patients/families to our Social Worker/Care Coordinators for additional counseling and resources. Any patient who scores positively on a depression screener (administered during triage) is flagged for our Licensed Clinical Social Worker, who through a warm hand-off administers additional screeners and schedules the patient to be seen by an in-house Mental Health provider. Finally, we have daily Social Services hours that are available to all members of our community.

      To be quite honest, I am still struggling with the costs vs. benefits of being one of the first health centers in the State to take on such a project. For those who were in a similar boat, but have since implemented the PRAPARE tool (or something similar), what argument finally convinced you and your team to move forward with the tool? Was it a grant for SDoH funding that came along? Or does the data from the tool truly provide unique insight into the needs of your patient population? Thanks in advance!

    • 1. What is your organization currently doing, planning to do, or needing, to train staff on Social Determinants of Health (SDoH) data?
      (Examples include educating staff on the importance of the social determinants, how it aligns with Patient-Centered Medical Home efforts, how to collect those determinants using the specific EHR system, and how to connect patients to available resources to meet the needs identified.)
      NC is working on implementing Medicaid Transformation. NC has broken the state into different regions. The first region will be going live in November of 2019. With the medicaid Transformation it will require all organizations accepting Medicaid be required to collect SDOH information (as outlined by the state) by the end of this year.

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