Standardizing Collection of Social and Economic Risk Data

Andrew Hamilton, RN, BSN, MS

Chief Informatics Officer, AllianceChicago

Session 13:

Agenda1. Present key challenges in standardizing social determinants of health

data in the EHR.

2. Describe why documenting patient-level social risks in the clinical setting is necessary.

3. Present the PRAPARE experience.a. Selecting and including key social risk concepts for screening and documentation.

b. Explain PRAPARE design, development, and implementation experiences.

c. Discuss spread to date and resources to support spread.

Poll Question #1

How much work has your organization completed toward using a tool to collect SDOH information from patients?

a) Haven’t downloaded the templateb) Downloaded the template, but haven’t started yetc) Just starting the projectd) Started implementing and seeing some resultse) Have successfully standardized collection of social dataf) Unsure or not applicable

Learning Objectives

Recognize key challenges in

standardizing collection of social determinants

data in EHRs.

Identify important concepts to be included when incorporating social determinants data.

Apply approaches employed by Community

Health Centers to standardize social

determinants data collection across four EHRs.

Key Challenges in Standardizing Data on Patient Social Risks

Multiple state and payer initiatives.

Logistics of workflow.

Lack of existing data and data value sets to accelerate

interoperability.

Poll Question #2

On a scale of 1 to 5, how effectively is your organization positioned to respond to social determinants data?

a) 1-Not at all effectiveb) 2-Somewhat effectivec) 3-Moderately effectived) 4-Very effectivee) 5-Extremely effectivef) Unsure or not applicable

What Determines Health

McGinnis et al., Health Affairs Vol 22(2)

Genetics, 30%

Medical Care, 10%

Social, 15%

Pt Choices, 40%

Environment, 5%

Bay Area Regional Health Inequities Initiative (BARHII). 2008. “Health Inequities in the Bay Area,” accessed November 28, 2012 from http://barhii.org/resources/index.html.

Why Collect Data on Social Determinants of Health (SDH)?

Are services

sustainable?

Socio-Ecological Medical Model

How well do we know our patients?

Discriminatory Beliefs (ISMS)

• Race• Class• Gender• Immigration

status• National origin• Sexual orientation• Disability

Institutional Power

• Corporations & other businesses

• Government agencies

• Schools

Social Inequities

• Neighborhood conditions - Social- Physical

• Residential segregation

• Workplace conditions

Risk Factors & Behaviors

• Smoking• Nutrition• Physical activity• Violence• Chronic Stress

Disease & Injury

• Infectious disease• Chronic disease• Injury (intentional

& unintentional)

Mortality

• Infant mortality• Life expectancy

HEALTH STATUSSOCIAL FACTORSHEALTHCARE

ACCESS

INDIVIDUAL HEALTH KNOWLEDGE

A FRAMEWORK FOR HEALTH EQUITY

UPSTREAM DOWNSTREAM

GENETICS Are services addressing SDH incentivized and sustainable?Are community partnerships adequate and integrated?

SDOH and Healthcare Delivery• The overall goal is to improve health, lower cost, and advance health equity.

Assess SDOH needs.

Link patients to community services.

Use data to evaluate the impact of creating a link between healthcare delivery and community services.

Develop sustainable business models to fund access to community services.

Health Leads CMS Accountable Health Communities

Health Begins PRAPARE In All Tools

Employment X X X X X

Food Insecurity X X X X X

Housing Instability X X X X X

Housing Condition X X

Financial Strain X X X

Utility Needs X X X

Education X X X X X

Social Support X X X X X

Physical Activity X X

Mental Health X X X

Substance Use X X

Immigration X X

Exposure to Violence X X X X X

Transportation X X X X X

Time to complete 5 min 5 min N/A 10 min N/A

PRAPARE Was Designed to Accelerate Systemic Population Health Improvement

Analyze standardized data

Publication pending. Do not quote or distribute without permission from NACHC.

Community Context Understand Patients Transform Care Impact Delivery System Redesign

• Upstream socio-ecological factors impact behaviors, access, outcomes, and costs.

• Inquiry & standardized data collection.

• Understand extent of patient & population complexity.

• New or improved social risk interventions/ community linkages.

• Better care management.• Empowered patients.

• Impact root causes of poor health.

• Improve outcomes, health equity, patient/staff experiences.

• Lower costs.• Establish ROI.

• Advocate for upstream investment.

• Achieve integrated, value-driven delivery system.

• Ensure interventions are sustainable.

Individual Patient Level Local Population Level

Local, State, and National

Levels

What Is PRAPARE?

Protocol for Responding to & Assessing Patients’ Assets, Risks, & Experiences:

A national standardized patient risk assessment protocol designed to engage patients in assessing & addressing social determinants of health (SDH).

PRAPARE = SDH screening tool + implementation/action process

Created by: National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, Institute for Alternative Futures in partnership with others, including AllianceChicago.

Timeline of Development

Developed domain selection criteria and

paper tool.

Piloted PRAPARE implementation in EHR and explore data utility.

PRAPARE Implementation &

Action Toolkit.

Year 12014

Year 22015

Year 32016

Dissemination

PRAPARE’s Unique Design Actionable at patient and population level.

Vetted and stakeholder engaged development process.

Environmental scan, stakeholder engagement, literature review, and align with national SDH initiatives and standards.

In the EHR to facilitate assessment & interventions (free templates).

Conversation starter and patient-centered.

Common core yet flexible:

Can be implemented in various existing workflows. Able to make more granular and/or add questions. Can be used in combination with other tools/data. Focus on standardizing the need, not question.

Publication pending. Do not quote or distribute without permission from NACHC.

PRAPARE Domains

CORE

UDS SDH Domains1. Race2. Ethnicity3. Veteran Status4. Farmworker Status5. English Proficiency6. Income7. Insurance8. Neighborhood9. Housing

Non-UDS SDH Domains10. Education11. Employment12. Material Security13. Social Integration14. Stress

OPTIONAL

Non-UDS SDH Domains1. Incarceration History2. Transportation3. Refugee Status4. Country of Origin5. Safety6. Domestic violence

PRAPARE asks 15 questions to assess 14 core SDH domains.

• 9 domains already asked for federal health center reporting (Uniform Data System) so can be auto-populated.

• 5 non-UDS domains informed by Meaningful Use Stage 3.

PRAPARE has 6 optional domains.

Find the tool at:www.nachc.com/research-data.com

Also includes neighborhood and optional questions (incarceration history, refugee status, safety, domestic violence).

PRAPARE Domain UDS ICD-10 IOM Meaningful Use HP2020 RWJF County

Health

Race / Ethnicity X X X X X

Farmworker Status X

Veteran Status X Explored, not adopted

Preferred Language X X X X

Income X X X X X

Insurance Status X X X

Housing X X X

Education X X X X X

Employment X X Explored, not adopted X X

Material Security X X X X X

Social Integration X X X X X

Stress X X X X

Transportation X

SDOH Data Elements in National Data Programs

Community Health Centers TodayLargest national network of primary/preventive care• 27+ million patients at 10,400+ sites.• 1 in 12 US residents.• 1 in 6 Medicaid beneficiaries.• 1 in 3 low income, uninsured.• 1 in 3 people in poverty.• 1 in 3 racial/ethnic minority individuals in poverty.• 1.3 million homeless persons.

• 965,000+ migrant farmworkers.

1400 Health Center Orgs.

Health Center Model of Care

Community governance. Located in / serve federally-designated medically underserved

areas. Non-profit, must be open to all. Comprehensive health services.

Care team, care integration, community partners. “Enabling” and social services.

Community needs assessments. Strict performance / accountability standards. Quality improvement / assurance plans.

PIL

OTWORK

FLOWSHealth

Center Who Where When How Rationale

CHC #1 Non-clinical staff (enrollment assistance, community health workers).

In waiting room. Before provider visit. Administered PRAPARE with patients who would be waiting 30+ mins for provider.

Provided enough time to discuss SDH needs.

CHCs #2 Nursing staff and/or Mas.

In exam room. Before provider enters exam room.

Administered it after vitals and reason for visit. Provider reviews PRAPARE data and refers to case manager.

Wanted trained staff to collect sensitive information. Waiting area not private enough to collect sensitive info.

CHC #3 Non-clinical staff (patient navigators, patient advocates).

In patient advocate’s office.

After clinical visit when provider refers patient to patient navigator.

Patient advocates administer it and then can relay to provider in office next door.

Wanted same person to ask question and address need. Often administer PRAPARE with other data collection effort (Patient Activation Measure) to assess patent’s ability and motivation to respond to theirsituation.

CHC #4 Care Coordinators. In office of care coordinator.

When completing chart reviews and administering Health Risk Assessments.

Administered PRAPARE in conjunction with Health Risk Assessments.

Allows care coordinators to address similar issues in real time that may arise from both PRAPARE and HRA.

CHC #5 Any staff (from Front Desk Staff to Providers).

No wrong door approach.

No wrong door approach.

Allows everyone to be part of larger process of “painting a fuller picture of the patient” and taking part in helping the patient.

Publication pending. Do not quote or distribute without permission from NACHC.

Overview of Pilot Sites

GE Centricity Template

PRAPARE EHR Templates

• NextGen• eClinical Works• GE Centricity• Epic

Available for free after signing EULA at www.nachc.org/prapare

• Greenway Success EHS• Greenway Intergy• Allscripts• Meditab• Athena• Cerner

60% of all health centersCurrent 4 + New EHRs =

85-95% of all health centers

Currently available In development

PRAPARE Implementation & Action Toolkithttp://www.nachc.org/prapare

◼ Chapter 1: Understand the PRAPARE Project.

◼ Chapter 2: Engage Key Stakeholders.

◼ Chapter 3: Strategize the Implementation Process.

◼ Chapter 4: Technical Implementation with EHR Templates.

◼ Chapter 5: Develop Workflow Models.

◼ Chapter 6: Develop a Data Strategy.

◼ Chapter 7: Understand and Evaluate Your Data..◼ Chapter 8: Build Capacity to Respond to SDH Data.

◼ Chapter 9: Respond to SDH Data with Interventions.

◼ Chapter 10: Track Enabling Services.

Pilot Results (2015 and 2017)

Publication pending. Do not quote or distribute without permission from NACHC.

Easy to administer.

Possible to implement using various workflows

and staffing models.

Builds patient-provider relationship.

Identifies new needs.

Leads to positive changes at the patient, health center, and community / population levels.

Facilitates collaboration with community partners.

Importance of targeted messaging and staff support.

2015 PILOT RESULTSPercent of Patients with Number* of SDH “Tallies”

* Excludes low income

Publication pending. Do not quote or distribute without permission from NACHC.

N = 2,694 patients for all teams

0%

5%

10%

15%

20%

25%

30%

35%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22Tally Score

Alliance/Iowa Waianae New York Oregon Total3 CHCs 1 CHC 2 CHCs 1 CHC 7 CHCs

This health center pilot population had highest burden of chronic illness.

r = 0.61

Positive Correlation Between SDH Factors* and Hypertension: All Teams

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17Tally Score

% of POF % of the tally score with Hypertension* Excludes low income

Publication pending. Do not quote or distribute without permission from NACHC.

Examples of Using PRAPARE Data

Publication pending. Do not quote or distribute without permission from NACHC.

Patient-level improvements• Matching Rx and Tx plans to

patient circumstances.• In-house and community

assistance programs.

Organizational- and community-level actions• Expand enabling services.• Mobile outreach.• Prioritize development of

community partnerships.• Referral resource guides and

referral networks.• Risk segmentation and

stratification.

System-level• Payer and delivery

system partner engagement.

• Alternative payment methodologies.

Top Story in Sioux City Journal on June 23, 2017

http://bit.ly/PRAPARESiouxland2

PRAPARE Reach as of Feb 2018

750+ have downloaded a PRAPARE EHR template, but reach is higher.Dominant screening tool used by health centers.

Not just health centers.Hospitals, health systems, ACOs, health plans, population health vendors.

Adopted by CMS Accountable Healthcare Communities.This CMMI demonstration borrowed 2 PRAPARE domains for its 5 domain social risk screening tool.

Happy to work with new vendors and partners!Please reach out to NACHC before you get started.

Key Questions Remain• What are the best ways (workflows) to capture SDOH data?

• How do we capture SDOH data for patients that have not yet engaged with the healthcare system?

• How do we use SDOH data to inform the patient’s care plan?

• What is the correlation between specific SDOHs and health outcomes?

• What are effective business models to support sustainable and effective programs related to SDOH?

Acknowledging Our Funders

Questions and Answers

ahamilton@alliancechicago.org

Andrew Hamilton, RN, BSN, MSChief Informatics Officer/Deputy Director

AllianceChicago312.267.2017

To sign up for the PRAPARE listserv, email prapare@nachc.org