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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.
1) How did you decide on the workforce needed to address SDoH?
In our state of Pennsylvania, we current are engaged in a patient centered medical home (PCMH) learning network of community health centers across the state. There have been several topics that range from care coordination and hospital follow up, community health workers, and SDoHs at our reoccurring learning meetings. This initiative is being pushed by the state onto MCOs to drive more value based care, and has shifted several incentive program and added requirements to screen for SDoH onto CHC such as mine. More recently at a conference with the network, we are expected this year to begin coding ICD codes for SDoHs. We’ve begun efforts it screen by implementing the PRAPARE screening tool in our enrollment tablets, and plan to add these codes in our EHR soon as well.
1. Name: Juan Castro, MPH
2. Organization: Family Practice & Counseling Network
3. Role: Quality Assurance Manager
4. What are you looking forward to learning by the end of this month? I want to be able to help support our health centers’ capacity to address the need to screen and manage SDoHs in our patient population.
5. Optional: Share a picture of your pet or favorite animal photo!
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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