supporting health center transformation with …€¦ · custom template and vendor template...

1

SUPPORTING HEALTH CENTER TRANSFORMATION

WITH SOCIAL DETERMINANTS OF HEALTH

© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary

Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use by NACHC, its partners, and

authorized recipients. Do not publish, copy, or distribute this information in part of whole without written consent from NACHC.

Michelle Jester

Deputy Director of Research

National Association of Community Health Centers

2

WHAT ARE SOCIAL

DETERMINANTS OF HEALTH AND

WHY IT IS IMPORTANT TO HAVE

STANDARDIZED DATA ON SDH?

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.

Figure 1

WHY COLLECT DATA ON SOCIAL DETERMINANTS OF HEALTH?SDH DRIVE OUTCOMES BEFORE PATIENTS RECEIVE CARE

How well

do we

know our

patients?

Are services

and

community

partnerships

addressing

SDH

available,

adequate,

Integrated,

incentivized,

and

sustainable?

3

SOCIAL DETERMINANTS OF HEALTH DRIVE OUTCOMES &

COSTS

4

5

Business Case for Social Determinants Work

◼ Population Health Management

▪ Risk stratification, segmentation, and adjustment

▪ Re-design care team, enabling services, and community partnerships

◼ Meet Goals of the Quadruple Aim

▪ Improved outcomes—address the root causes of poor health!

▪ Improved patient experience

▪ Improved provider experience

▪ Decreased cost

◼ Demonstrate Health Center Value

◼ Prepare your organization for value based pay

◼ Become leaders in your state to inform social determinant policy and practice

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Using Social Determinants Data for Population Risk

Segmentation

Source: Oregon Primary Care Association

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Community Context

Understand Patients

Transform Care

Impact & Value

Reform and Sustainability

Using Social Determinants Data to Accelerate

Transformation and Shift to Value-Based Pay

Root

causes of

poor health

and higher

costs

Under-

stand and

document

root causes

that make

patients

more

complex

New or

improved

interventions/

community

linkages

Better care

management

Empowered

patients

Lower costs

Improve

outcomes

Establish

ROI

Impact root

causes of poor

health

Better

payment and

risk adjustment

Value-driven

care delivery

Integrated

delivery system

Analyze standardized data

Publication pending. Do not quote or

distribute without permission from NACHC,

AAPCHO, and OPCA.

PRAPARE

Why Is It Important for Us to Collect Standardized Patient-

Level Data on the Social Determinants of Health?

Patient and Family

Care Team Members

Health Center

Community/Local

Health System

State and National

Policies

Individual

level

Organizational

level

Payer level

Empowered to improve health and wellbeing

Better manage patient and population needs

Design care teams to deliver patient-centered

care and better allocate limited resources

Integrate care through cross-sector partnerships,

develop community-level redesign strategy for

prevention, and advocate to change local policies

Execute payment models that sustain value-

based care (incentivize the social risk

interventions and partnerships, risk adjustment)

Ensure capacity for serving complex patients,

including uninsured patients

8

System/

Community

level

Payment

Policy level

Publication pending. Do not quote or distribute without permission from NACHC, AAPCHO, and OPCA.

9

WHAT IS PRAPARE AND WHY

SHOULD MY HEALTH CENTER USE

IT?

A national standardized patient risk assessment protocol built into the EHR that wasdesigned to engage patients in assessing & addressing social determinants of health

PRAPARE = SDH screening tool + implementation/action process

What is PRAPARE?

10

Customizable Implementation and Action Approach

Assess Needs Respond to Needs

At the Patient and Population Level

11

Why PRAPARE?

• STANDARDIZED, INTEROPERABLE, and WIDELY USED– Measures Linked with ICD-10 codes and aligned with national initiatves (UDS, ICD-10, IOM, MU, NQF, etc)

– Dominant SDH risk screening tool used by health centers and increasingly used by other organizations (~1,000 orgs)• Hospitals, health systems, ACOs, health plans, population health vendors

• EVIDENCE-BASED and STAKEHOLDER-DRIVEN– Developed and tested by health centers

• PATIENT-CENTERED– Meant to facilitate conversations and build relationships with patients. Standardize the need rather than the question

• WORKFLOW AGNOSTIC– Can fit within existing workflows & be combined with other tools/data (ex: non-clinical staff, clinical staff, self-assessment)

• FREE EHR Templates: – eClinicalWorks, Epic, NextGen, GE Centricity, Greenway Intergy

– Working on Athena, Allscripts

• FREE PRAPARE Implementation and Action Toolkit– Accompanying resources, BPs, & lessons learned to guide users on PRAPARE implementation

Publication pending. Do not quote or distribute without

permission from NACHC, AAPCHO, and OPCA.

HOW WAS PRAPARE DEVELOPED?

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Identified 16 Core Social Determinants of Health

Sensitivity

Burden of Data

Collection

Action-ability

Aligned with National

Initiatives:

* Healthy People 2020

* ICD-10

* Meaningful Use Stage 3

* NQF on Risk Adjustment

Literature Review

Experience of Existing

ProtocolsStakeholder Feedback

Criteria

Note: Accountable Healthcare

Communities Tool did not exist in

2014

Publication pending. Do not quote or distribute without

permission from NACHC, AAPCHO, and OPCA.

What Questions Are in PRAPARE?

Find the tool at www.nachc.org/prapare

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Core

1. Race* 10. Education

2. Ethnicity* 11. Employment

3. Veteran Status* 12. Material Security

4. Farmworker Status* 13. Social Isolation

5. English Proficiency* 14. Stress

6. Income* 15. Transportation

7. Insurance* 16. Housing Stability

8. Neighborhood*

9. Housing Status*

Optional

1. Incarceration

History

3. Domestic Violence

2. Safety 4. Refugee Status

Optional Granular

1. Employment: How

many hours worked

per week

3. Insurance: Do you

get insurance through

your job?

2. Employment: # of

jobs worked

4. Social Support: Who

is your support

network?


* UDS measures are automatically populated into PRAPARE EHR templates. You do NOT need to ask those questions multiple times!

10 translations of PRAPARE

now available!

http://www.nachc.org/prapare

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Crosswalk between PRAPARE and Other National Initiatives


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PRAPARE Coding and Data Dictionary for Enhanced

Interoperability

• Crosswalks including ICD-10,

LOINC, SNOMED codes

• Many PRAPARE EHR

templates have used

crosswalks to map PRAPRAE

measures to ICD-10 codes

• New proposed codes for

PRAPARE responses in

process: ICD-10, LOINC

• PRAPARE Data

Documentation available in

Toolkit

FREE EHR Templates Available*:

NextGen*

eClinical Works

GE Centricity*

Epic

Cerner*

Greenway Intergy

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

In development:

Athena—Summer 2019 release

Allscripts

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PRAPARE EHR TEMPLATES

75% of all health centers

Current 7 + New EHRs =

85-95% of all health centers

* Automatically map to ICD-10 Z codes so you can easily add relevant Z codes to problem or diagnostic list

Excel File Template also available

for health centers not on one of

these EHRs


eCl inicalWorks:

Free configuration guide to build PRAPARE into social history section OR

PRAPARE Smart Form at $1,000 per database. Includes PRAPARE risk tally scoring methodology

Advantages & tradeoffs for each

Greenway Intergy

Need Intergy 11 or higher to capture PRAPARE data

Some data in demographics as usual. Other data in PRAPARE template. Health Choice Network has crosswalk

GE Centr ici ty:

Custom template and Vendor template mapping PMS to EHR

Features:

Data maps to existing data in EHR and PMS (except eCW)

Some templates match to ICD-10 Z codes and added to problem/diagnostics list

Reminder/Alert systems to notify care team member when certain PRAPARE data is due to be collected

WHAT DO I NEED TO KNOW ABOUT THE

PRAPARE EHR TEMPLATES?

Recorded demos of each PRAPARE EHR template available at www.nachc.org/prapare

Available in Chapter 4 of the PRAPARE Implementation and Action Toolkit at www.nachc.org/prapare



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GREENWAY INTERGY PRAPARE TEMPLATE

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GREENWAY INTERGY PRAPARE REPORTS

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Courtesy of

Siouxland Community

Health Center &

AllianceChicago

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PRAPARE ECW SOCIAL HISTORY NOTES

Instructions available in the

PRAPARE eCW Configuration

guide available in Chapter 4 of

PRAPARE Implementation and

Action Toolkit at

www.nachc.org/prapare


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PRAPARE ECW SMART FORM

PRAPARE eCW Smart Form

available in Chapter 4 of

PRAPARE Implementation and

Action Toolkit at



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/pop levels

Facilitates collaboration with community partners

Demonstrates patient complexity23

WHAT WE’VE LEARNED FROM PRAPARE USE


24

HIGH RISK PATIENTS FACE MORE SOCIAL DETERMINANT

RISKS THAN GENERAL POPULATION

0%

5%

10%

15%

20%

25%

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

Pe

rce

nta

ge

of

Pa

tie

nts

Tally Scores


High Risk Total

(N= 2,679)

General Pop Total

(N = 4,432)

Overall Total

(N = 7,111)

HOW PRAPARE DATA HAS BEEN USED TO IMPROVE CARE

DELIVERY AND HEALTH OUTCOMES

Ensure prescriptions and treatment plan

match patient’s socioeconomic situation (all)

Build new or expand existing services in-

house for same-day use as clinic visit

(enabling services, mobile outreach,

children’s book corner, food banks,

clothing closets, wellness center,

transportation shuttle, etc)

Build partnerships with local organizations

(transportation partnerships)

Use for Population Segmentation/Risk

Stratification

Inform health delivery redesign (ex:

Medicaid and Medicare ACO discussions)

INDIVIDUAL Level

POPULATION Level

System and

Policy Level

Streamline care management plans for better

resource allocation (ex: Hawaii)

Use data for “seat at the table” with payers

to discuss sustainable payment and APM

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Guide work of local foundations (ex: New York

housing)


Calculate ROI for social determinant

interventions and revenue generated from

reducing no-show rates

◼ 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

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PRAPARE IMPLEMENTATION & ACTION TOOLKIT


◼ Chapter 8: Build Capacity to Respond to SDH Data

◼ Chapter 9: Respond to SDH Data with Interventions

◼ Chapter 10: Track Enabling Services

Plus:

Readiness

Assessments

Best Practices

Webinars

FAQs

Translations

and more


27

HOW DO WE COLLECT SENSITIVE

SOCIAL DETERMINANTS DATA?

28

Sample Workflow Models for PRAPARE Data Collection

Who Where When How Rationale

Non-clinical staff

(patient navigator,

community health

workers)

In waiting

room or in

staff office

Before of after provider

visit

Administered PRAPARE

with patients who would be

waiting 30+ mins for provider

Provided enough time to discuss SDH needs.

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 their situation.

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

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

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

Patient Self-

Assessment

At home, in

waiting room,

etc.

Before visit with provider Self-administered using

email, tablets, kiosks, etc.

Low burden on staff to collect data. Privacy for

patient to complete assessment. Utilize time

when patient would otherwise be waiting. Staff

time can be used to discuss results with patients

to address needs.

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

◼ Empathic Inquiry: combines methods of motivational interviewing and trauma-informed care to

promote partnership, trust, affirmation, engagement, and respect

◼ Shift mindset from “collecting data” to “getting to know your population—one person at a time”

◼ Explain why you are collecting this information, how it will be used, and options for follow-up

◼ One person’s data is another person’s difficult life experiences, so it’s important to emphasize:

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Collecting Sensitive Social Determinants Data Using

Empathic Inquiry

SensitivityPatient

EngagementCompassion

Patient

Engagement

Privacy

Patient

Autonomy

Patient

Priorities

Strengths,

Assets,

Interests

Minimize

patient

distress

Avoid

stigma

1) Start with relationship and engagement

▪ Introduce yourself and explain the what, why, and how long of screening process

▪ Ask for permission to have conversation, acknowledge sensitivity of questions, and give permission to

decline at any moment

2) Empathize to create and convey understanding

▪ Ask about patient’s priorities, interests, experiences, and perspectives on experiences

▪ Convey understanding through attentive non-verbal cues and through reflective listening “Sounds like

you’re tired of bouncing around between housing situations.” or “Getting help with your phone bill

sounds like your highest priority”

3) Support by focusing on strengths

▪ Provide affirmations of patient’s strength and resilience “Sounds like you’ve been working hard to

make ends meet. You are clearly very resourceful and creative”. “It takes a lot of strength to get

through such a tough situation. You really have a lot of grit.”

4) Summarize and plan for action and collaboration

▪ Ask if patient wants referrals to other team members or community resources

5) End with empathy 30

Key Steps for Empathic Inquiry Conversation

Source: “Patient-Centered Social Determinants of Health Screening Conversation Guide” by the Oregon Primary Care Association.

◼ By Waianae Coast Comprehensive Health Center in Hawaii

https://www.youtube.com/watch?v=iQjJ_QsDvmI&list=PLvoNbrkrX4YRsfMJz3qJMGrwZGCWPf

sqE&index=3&t=2s

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Video Demonstrating Effectiveness and Appropriateness

of Empathic Inquiry Approach

https://www.youtube.com/watch?v=iQjJ_QsDvmI&list=PLvoNbrkrX4YRsfMJz3qJMGrwZGCWPfsqE&index=3&t=2s

◼ Make patients feel comfortable. Talk normally to them to have a conversation

◼ Create safe, non-judgmental space. Don’t react to any of their answers

◼ Let them know you’re here to help

◼ If patient doesn’t want to speak, tell them they can just nod their head “yes” or “no”

◼ Don’t force resources on them but let them know about them and that you’re happy to talk about

them later if they want to reach out

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Best Practices for Understanding Needs of Patients

When Not Actively Expressed

◼ Deep-dive into workflow models to collect social determinants of health data in clinic workflow

◼ Best practices for building capacity to respond to social determinant of health needs

◼ Aligning work across the Dakotas for interoperability

◼ Tips for getting started

◼ Strategies for sustaining work on social determinants when don’t have extra funding

◼ Draft implementation plans

◼ Troubleshoot challenges33

October In-Person Training

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For More Information on PRAPARE

Visit


Join our listserv!

Email [email protected]

Email Michelle Jester at

[email protected].

Resources Available to Support

Health Centers, PCAs, & HCCNs

PRAPARE Implementation and Action Toolkit

Free EHR templates for Cerner, eCW, Epic, GE

Centricity, Greenway, NextGen

PRAPARE Readiness Assessments for CHCs &

PCAs

Recorded Webinars on PRAPARE, Workflows,

EHR Templates, etc.

PCA/HCCN Case Studies

10 translations of PRAPARE including Spanish,

Somali, Arabic, Chinese, Tagalog, Korean,

Vietnamese, and more!


mailto:[email protected]


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Questions & Discussion

For more information, visit www.nachc.org/prapare

To receive the latest updates on PRAPARE, join our listserv!

Email Michelle Jester at [email protected].



supporting health center transformation with …€¦ · custom template and vendor template...

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