Post on 27-Dec-2019
4/19/2016
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This project was made
possible with funding from:
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COLLECTING SOCIAL DETERMINANTS
OF HEALTH DATA USING PRAPARE
TO REDUCE DISPARITIES, IMPROVE
OUTCOMES, AND TRANSFORM CARE
WEBINAR AGENDA
Topic Facilitators Minutes
Importance of Collecting Data on the
SDH
Michelle Proser, NACHC 15 mins
How We Created PRAPARE Michelle Jester, NACHC 10 mins
Status of PRAPARE and How You Can
Use PRAPARE at Your Health Center
Alicia Atalla-Mei, OPCA 10 mins
What We’ve Learned Rosy Chang Weir, AAPCHO 15 mins
Using Data on the SDH Michelle Jester, NACHC and
Tuyen Tran, AAPCHO
15 mins
Next Steps and Q&A Michelle Proser, NACHC 25 mins
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WHY IS IT IMPORTANT TO
COLLECT STANDARDIZED DATA
ON THE SOCIAL DETERMINANTS
OF HEALTH?
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Under value-based pay environment, providers are held
accountable for costs and outcomes
Difficult to improve health & wellbeing and deliver value
unless we address barriers
Current payment systems do not incentivize approaching
health holistically and in an integrated fashion
Providers serving complex patients often penalized without risk
adjustment
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HEALTH, ACCOUNTABILITY & VALUE
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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
WHAT IS DRIVING THE NEED TO COLLECT DATA ON
THE SOCIAL DETERMINANTS OF HEALTH (SDH)?
How well
do we
know our
patients?
Are services
addressing
SDH
incentivized
and
sustainable?
Are
community
partnerships
adequate
and
integrated?
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Social and Economic
Factors (40%)
Clinical
Care (20%)
Health
Behaviors
(30%)
Physical
Environment (10%)
Project Goal: To create, implement/pilot test, and promote a
national standardized patient risk assessment protocol to assess
and address patients’ social determinants of health (SDH).
PRAPARE:
PROTOCOL FOR RESPONDING TO & ASSESSING PATIENT ASSETS,
RISKS, & EXPERIENCES
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PRAPARE
Assessment Tool
To Identify Needs
Protocol to
Respond to Needs
• Paper Tool
• EHR Templates
• List of Granular
Needs
• ICD-10 Z Codes
• Workflow Diagrams
• Staff Training
Curriculum
• Implementation and
Action Toolkit
• Examples of Interventions
• Guidance on how to build
capacity
• Appendix of Resources
• Guidance on informing
policy and payment
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Community Context
Understand Patients
Transform Care
Impact DemonstrateValue
FROM DATA TO PAYMENT: CONNECTING THE DOTS
Upstream
socio-
ecological
factors
impact
behaviors,
access,
outcomes,
and costs
Inquiry &
standardized
data
collection
Under-
stand extent
of patient &
population
complexity
New or
improved
non-clinical
interventions,
enabling
services,
and
community
linkages
Impact
root causes
of poor
health
Improve
outcomes,
patient/staff
experiences
Lower total
cost of care
Negotiate
for payment
change
Ensure
sustainability
of
interventions
Analyze standardized data
Individual Patient
Level
Local Population
Level
State and National
Level
HOW DID WE CREATE PRAPARE?
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Used evidence to
apply domain criteria
Literature reviews of SDH associations with cost and health outcomes
Monitored and/or aligned with national initiatives
• HP2020
• RWJF County Health Rankings
• ICD-10
• IOM on SDH in MU Stage 3
• NQF on SDH Risk Adjustment
Collected existing protocols from the field
• Collected 50 protocols (many not validated)
• Interviewed 20 protocols
• Identified top 5 protocols
Engaged stakeholders for feedback
• Braintrust (advisory board) discussion
• Surveyed stakeholders
• Distributed worksheet to potential users for feedback
Identified
15 Core
Domains
IDENTIFYING CORE DOMAINS
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Critiera:
1) Actionability
2) Alignment with National Initiatives
3) Evidence in Research
4) Burden of Data Collection
5) Sensitivity
6) Stakeholder Feedback
PRAPARE DOMAINS
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 :
http://www.nachc.com/research-data.cfm
UDS SDH Domains
1. Race
2. Ethnicity
3. Veteran Status
4. Farmworker Status
5. English Proficiency
6. Income
7. Insurance
8. Neighborhood
9. Housing
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Core
Non-UDS SDH Domains
10. Education
11. Employment
12. Material Security
13. Social Integration
14. Stress
Optional
Non-UDS SDH Domains
1. Incarceration History
2. Transportation
3. Refugee Status
4. Country of Origin
5. Safety
6. Domestic Violence
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CROSSWALK OF PRAPARE WITH OTHER NATIONAL INITIATIVES
PRAPARE Domain UDS ICD-10 IOM Meaningful
Use (2 and 3)
HP2020 RWJF County
Health
Race/Ethnicity X X X X X
Farmworker Status X
Veteran Status X Seeking
comments
English Proficiency X X X X
Income X X X X X
Insurance Status X X X
Neighborhood X X X X X
Housing X X X
Education X X X X X
Employment X X X X X
Material Security X X X X X
Social Integration X X X X X
Stress X X X X
Selected questions to measure SDH
domains
• Pulled from existing validated questions when possible (few validated questions exist)
Questions Reviewed by
Health Literacy Expert
• To ensure language matched common reading levels
Performed Cognitive Testing on Questions
• Each pilot site performed cognitive testing with at least 10 patients
Pilot Tested Questions
• Revised as necessary after pilot testing
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VALIDATING THE TOOL
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EXAMPLES OF NEXTGEN TEMPLATES
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EXAMPLES OF NEXTGEN TEMPLATES
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WHAT IS THE STATUS OF
PRAPARE?
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TIMELINE OF THE PROJECT
Year 1
2014
•Develop PRAPARE tool
Year 2
2015
•Pilot PRAPARE implementation in EHR and explore data utility
Year 3
2016
•PRAPARE Implementation & Action Toolkit
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Dis
se
min
atio
n
PRAPARE PILOT TESTING IMPLEMENTATION TEAMS AND
ELECTRONIC HEALTH RECORDS
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IN DEVELOPMENT: IMPLEMENTATION AND ACTION TOOLKIT
Categories Examples of Potential Resources to Include
Step 1: Understand the Project Project overview, project framework, defining risk, case studies, FAQs
Step 2: Engage Key Stakeholders Messaging materials, change management guidance
Step 3: Strategize the Implementation Plan Readiness assessment, PDSA materials, 5 Rights Framework, Implementation
timeline, progress reports, legal documents
Step 4: Technical Implementation PRAPARE paper assessment, data documentation, EHR templates, sample
data dictionaries, data specifications, data warehouse and retrieval strategies,
guidelines for using design and requirements documents
Step 5: Workflow Implementation Workflow diagrams, data collection training curriculum, lessons learned and
best practices
Step 6: Understand and Report Your Data Reporting requirements, sample database, sample data outputs, sample data
analyses and reports, cross-tabulating data, evaluation protocol, population-
level planning, guidelines for data integration
Step 7: Act on Your Data Strategy for detecting risk, report on best practices and processes for using SDH
data, examples of SDH interventions, SDH response codes, linking to enabling
services codes
Step 8: Use Your Data to Drive Payment and
Policy Transformation
Strategy to engage payers, funding SDH efforts, data visualization templates
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PRAPARE IS A NATIONAL MOVEMENT!
• Health centers in 8
states are either already
using PRAPARE or are
planning to begin using
PRAPARE in 2016
• Health centers, state
associations, regional
networks, and other
health care
organizations in 20+
other states interested
in using PRAPARE
Use and Interest in PRAPARE
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HOW CAN PRAPARE BE USED AT
YOUR ORGANIZATION?
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• How will tool be administered to the patient to ensure that it accurately identifies the SDH the patient may have? Right Information
• Who will collect the data and who will address the social determinants identified? Right Person
• How will resource information be organized so that it is readily available and standardized for all?
Right Intervention Format
• How is the appropriate care team member notified to address the SDH identified? Right Channel
• When in the patient visit does it make sense to administer the tool and when is the best time to address identified SDH?
Right Time in Workflow
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IMPLEMENTING PRAPARE:
USING THE FIVE RIGHTS FRAMEWORK
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SAMPLE WORKFLOWSHealth
Center
Who Where When How Rationale
CHC #1 Non-clinical staff
(enrollment
assistance)
In exam 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,
and community
health workers)
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 their situation.
CHC #4 Medical Assistants In exam room Before provider MAs administer PRAPARE
while patient is roomed but
before provider.
Want to get patient in to exam room as
quickly as possible. However, often don’t
finish because provider comes in to exam
room.
CHC #5 Care Coordinators No wrong door
approach
No wrong door
approach, but mostly
as care coordinators
complete chart
review and HRA
Allows staff to address similar issues in
real time that may arise from both
PRAPARE and HRA
WHAT HAVE WE LEARNED FROM
PRAPARE?
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WHAT WE’VE LEARNED FROM PILOT TESTING
Easy to use:
On average, takes ~9
minutes to complete
form
Emotional Toll on
Staff
Staff find value in the
tool: Helps them better
understand patients
and build better
relationships with
patients
Patients appreciate
being asked and feel
comfortable answering
questions
Identifies New Needs,
Often Leading to New
Community Partnerships
Made minor revisions
to tool based on pilot
testing feedback
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COMMON CHALLENGES ENCOUNTERED WHEN USING
PRAPARE AND SOLUTIONS
Challenge: Staff and Patients Don’t Understand Why
Doing PRAPARE
Solution: Use short script to explain to staff &
patients why health center is collecting this
information. Message around better understand
patient and patient’s needs to provide better care
Challenge: Have too much going on now to add
another project
Solution: Don’t market PRAPARE as new big
initiative but as project that aligns with other work
already doing (care management, ACO, enabling
services, etc)
Challenge: How do we
implement this without
increasing visit time?
Solution: Find “Value-Added”
time, whether in waiting room,
during rooming process, or
after clinic visit
Challenge: Fitting PRAPARE into
Workflow
Solution: Incorporate into other
assessments to encourage
completion (Health Risk
Assessment, Depression Screening,
Patient Activation Measure, etc)
Challenge: Inability to Address SDH
Solution: Message “Have to start
somewhere and do the best we can
with what we have. Collecting
information will help us figure out
what services to provide.”
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PERCENT OF PATIENTS WITH NUMBER OF SDH
“TALLIES”
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 22
Tally Score
Alliance/Iowa Waianae New York Oregon Total3 CHCs 1 CHC 2 CHCs 1 CHC 7 CHCs
N = 2,694 patients for
all teams
DATA RESULTS
SDH risks vary by community
Most common risks:
High stress
Having less than a high school education
Uninsured
Unemployed
Preference for language other than English
But, patients are very socially integrated,
Half of patients in our pilot test see people that they care about more
than 5+ times a week.
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MATERIAL SECURITY
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Food Clothing Utilities Rent/mortgage
payment
Transportation Child care Medicine or
medical care
Health
Insurance
Phone
Alliance/Iowa Waianae New York Oregon All Teams
N = 2,980 for all teams
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 17
Tally Score
% of POF % of the tally score with Hypertension
r = 0.61
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USING DATA ON THE SOCIAL
DETERMINANTS OF HEALTH
HOW PRAPARE DATA HAS BEEN USED TO IMPROVE CARE
DELIVERY AND HEALTH OUTCOMES
Ensure prescriptions and treatment plan match
patient’s socioeconomic situationBuild services in-house for same-day use
as clinic visit (children’s book corner,
food banks, clothing closets, wellness
center, transportation shuttle, etc)
Build partnerships with local community based
organizations to offer bi-directional referrals and
discounts on services (ex: Iowa transportation)
Create risk score to inform risk
adjustment
Inform both Medicaid and Medicare ACO
discussions and care management policies
Better Understand
INDIVIDUAL
Patient’s
Socioeconomic
Situation
Better Understand
Needs of Patient
POPULATION
Drive STATE and
NATIONAL Care
Transformation
Refer patients to needed social services, whether
in-house or through community partnership
Improve Community Resource Guide to
ensure accuracy and appropriateness
Inform advocacy efforts related to local
policies around SDH
Streamline and expand care management plans to
better allocate resources to areas most in need
Inform payment reform and APM discussions with
state agencies (e.g., Medicaid) on caring for
complex patients 34
Guide policies to incentivize integrated
care with social services
Guide work of local foundations to pay
for non-clinical services and partnerships
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Few
resources
Many
resources
He
alt
h C
en
ter
Re
so
urc
es
Local Community Resources
Substantial resources within
the health center
Limited resources in
the local community
Substantial resources
within the health center
Substantial resources in
the local community
Limited resources in
the local community
Limited resources
within the community
health center
Substantial resources in
the community
Limited resources within
the health center
ASSESS WHERE YOU ARE IN TERMS OF RESOURCES
(PEOPLE, PROCESSES, TECHNOLOGY)
NEED
Standardized data on patient
risk
RESPONSE
Standardized data on
interventions
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BOTH are necessary to demonstrate health center value
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AAPCHO DATA COLLECTION PROTOCOL:
THE ENABLING SERVICES ACCOUNTABILITY PROJECT
CATEGORY CODE Minutes
CASE MANAGEMENT ASSESSMENT CM001
CASE MANAGEMENT TREATEMENT AND
FACILITATION
CM002
CASE MANAGEMENT REFERRAL CM003
FINANCIAL COUNSELING/ELIGIBILITY
ASSISTANCE
FC001
HEALTH EDUCATION/SUPPORTIVE
COUNSELING
HE001
INTERPRETATION IN001
OUTREACH OR001
TRANSPORTATION TR001
OTHER OT001
Enabling Services
Accountability Project
(ESAP)
The ONLY standardized
data system to track
and document
non-clinical enabling
services that help
patients access care.
CONCEPTUAL FRAMEWORK
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Appropriate Care
(For health condition in question,
for example, # of doctor visits,
exams/tests levels…)
Health Outcomes
(For example, ideal
outcomes, reduced
complications, ED visits,
etc..)
Enabling Services & other non-clinical interventions
Social Determinants of
Health
(PRAPARE Domains:
Race/ethnicity, poverty
employment, English
proficiency, etc..)
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NEXT STEPS
NEXT STEPS
Complete Implementation &
Action ToolkitPhase IISpread
2016
Including:
* Free EHR Templates—by
May
* Training Materials—by
this summer
* Model Interventions to
Address the SDH—by this
summer
Including:
* Standardized data on
Interventions
• National PRAPARE
Learning Network
• State Based Action groups
* Validation
* Translation
* Pediatric PRAPARE Tool
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PRAPARE resources will be posted at www.nachc.com/research
PRAPARE Tool
Implementation steps and timeline
Data Documentation
AAPCHO’s ESAP technical and other resources at http://enablingservices.aapcho.org.
PRAPARE info and listserv signup: Michelle Jester, mjester@nachc.org
AAPCHO ESAP technical assistance: Tuyen Tran, ttran@aapcho.org
RESOURCES AVAILABLE TO YOU
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Stay tuned for date and time!! Email Michelle and mjester@nachc.org if interested
Will cover the following:
Steps to implement the NextGen template in another clinic’s EHR system
The particulars of using the NextGen PRAPARE template
A health center’s experience in redesigning or modifying workflow to collect and respond to the
data on social determinants
How the NextGen PRAPARE template can expedite the reporting and aggregation of data and
be used for patient and population-level interventions
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PRAPARE NEXTGEN-SPECIFIC WEBINAR
4/19/2016
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QUESTIONS AND DISCUSSION