Session 13: Standardizing Collection of Social and ... · 5/13/2018 · • Establish ROI. •...
Transcript of Session 13: Standardizing Collection of Social and ... · 5/13/2018 · • Establish ROI. •...
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
Andrew Hamilton, RN, BSN, MSChief Informatics Officer/Deputy Director
AllianceChicago312.267.2017
To sign up for the PRAPARE listserv, email [email protected]