COLLECTING SOCIAL DETERMINANTS OF HEALTH DATA USING PRAPARE This - PowerPoint PPT Presentation

COLLECTING SOCIAL DETERMINANTS OF HEALTH DATA USING PRAPARE This project was made possible with funding from: TO REDUCE DISPARITIES, IMPROVE OUTCOMES, AND TRANSFORM CARE 1

AGENDA To Topic Importance of Collecting Data on the SDH Background of PRAPARE How You Can Use PRAPARE and What We’ve Learned Tracking Interventions through Enabling Services Q&A 2

BACKGROUND ON PRAPARE 3

HEALTH, ACCOUNTABILITY & VALUE ¡ 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 4

WHAT IS DRIVING THE NEED TO COLLECT DATA ON THE SOCIAL DETERMINANTS OF HEALTH (SDH)? Figure 1 Are services addressing How well Physical Environment SDH do we (10%) incentivized know our Social and Economic and patients? Factors (40%) sustainable? Are community partnerships adequate Health and Behaviors integrated? (30%) Clinical Care (20%) Bay Area regional Health Inequities Initiative (BARHII). 2008. “Health Inequities in the Bay Area”, accessed November 28, 2012 from 5 http://barhii.org/resources/index.html.

PR PRAP APAR ARE: : PROTOCO PR COL F FOR R RESPO SPONDI NDING T NG TO & ASSE & ASSESSI SSING P NG PATI TIENT NTS’ S’ ASSE ASSETS, R S, RISKS, & E SKS, & EXPE XPERIENCE NCES S Project Goal: To create, implement/pilot test, and promote a na nationa tional s l sta tanda ndardized pa dized patient risk a tient risk assessm ssessment pro ent protocol ocol to assess and address patients’ social determinants of health (SDH). PRAP APAR ARE As Assessment T Tool + Protocol t to To I Identify N Needs Respond t to N Needs in E Electronic Health R h Record 6

TIMELINE OF THE PROJECT • Develop PRAPARE tool Year 1 Dissemination 2014 • Pilot PRAPARE implementation Year 2 in EHR and explore data utility 2015 • PRAPARE Implementation & Year 3 Action Toolkit 2016 7

DEVELOPING PRAPARE Experience of Existing Stakeholder Feedback Protocols Literature Review Aligned with National Initiatives: Action- Burden of ability * Healthy People 2020 Data * ICD-10 Collection * Meaningful Use Stage 3 Criteria * NQF on Risk Adjustment Sensitivity Identified 15 Core Social Determinants of Health 8

PRAPARE DOMAINS Cor Core e Opt Optional ional 1. Incarceration 3. Domestic Violence UDS SDH Domains Non-UDS SDH Domains History (MU-3) 2. Safety 4. Refugee Status 1. Race 10. Education 2. Ethnicity 11. Employment 3. Veteran Status 12. Material Security Older version in Spanish 4. Farmworker Status 13. Social Isolation 5. English Proficiency 14. Stress 6. Income 15. Transportation Find the tool at: 7. Insurance www.nachc.org/prapare 8. Neighborhood 9. Housing Status and Stability 9

WHAT WE’VE LEARNED FROM IMPLEMENTATION 11

PRAPARE PILOT TESTING IMPLEMENTATION TEAMS AND ELECTRONIC HEALTH RECORDS Other EHRs in Development or Interested: • Greenway • Allscripts • Athena • Cerner 12

WHAT WE’VE LEARNED FROM PILOT TESTING Easy to use: Patients appreciate On average, takes ~9 being asked and feel minutes to complete comfortable answering form questions Staff find value in the tool: Helps them better understand patients and build better relationships with patients Identifies New Needs, Often Leading to New Emotional Toll on Staff Community Partnerships

COMMON CHALLENGES ENCOUNTERED WHEN USING PRAPARE AND SOLUTIONS Cha hallenge: Staff and Patients Don’t Understand Why Cha hallenge: Have too much going on now to add Doing PRAPARE another project So Soluti tion: Use short script to explain to staff & Soluti So tion: Don’t market PRAPARE as new big initiative but as project that aligns with other work patients why health center is collecting this information. Message around better understand already doing (care management, ACO, enabling patient and patient’s needs to provide better care services, etc) Cha hallenge: How do we Cha hallenge: Fitting PRAPARE into Cha hallenge: Inability to Address SDH implement this without Workflow increasing visit time? Soluti So tion: Message “Have to start So Soluti tion: Incorporate into other somewhere and do the best we can So Soluti tion: Find “Value-Added” assessments to encourage with what we have. Collecting time, whether in waiting room, completion (Health Risk information will help us figure out during rooming process, or Assessment, Depression Screening, what services to provide.” after clinic visit Patient Activation Measure, etc) 14

PERCENT OF PATIENTS WITH NUMBER OF SDH “TALLIES” 35% N = 2,694 patients for all teams 30% 25% 20% 15% 10% 5% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Tally S Score Alliance/Iowa Waianae New York Oregon Total 3 CHCs 1 CHC 7 CHCs 1 CHC 2 CHCs

CORRELATION BETWEEN SDH FACTORS AND HYPERTENSION: ALL TEAMS r = 0.61 50% 40% 30% 20% 10% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Tally S Score % of POF % of the tally score with Hypertension

HOW PRAPARE DATA HAS BEEN USED TO IMPROVE CARE DELIVERY AND HEALTH OUTCOMES Better U Understand Build services in-house for same-day use Ensure prescriptions and treatment plan INDIVIDUAL AL as clinic visit (children’s book corner, food match patient’s socioeconomic situation Pa Patient’s banks, clothing closets, wellness center, Socioec So economi mic transportation shuttle, etc) Situ Si tuati tion Guide work of local foundations (ex: New Build partnerships with local community Better U Understand York housing) based organizations to offer bi-directional Needs o of P Patient referrals and discounts on services (ex: POPUL PO PULATI TION N Streamline care management plans for Iowa transportation) better resource allocation (ex: Hawaii) Inform both Medicaid and Medicare ACO Drive S STATE a and discussions (ex: Iowa, New York) Inform payment reform and APM NATIONAL AL C Care discussions with state agencies (e.g., Tr Transformation Medicaid) on caring for complex patients Create risk score to inform risk adjustment (ex: Oregon, Hawaii) (ex: Hawaii) 17

TRACKING INTERVENTIONS 18

¡ RES RESPONS ONSE E ¡ NEED NEED § Standardized data on § Standardized data on interventions patient risk BOTH a are n necessary t to d demonstrate he health c h center v value 19

RESPONSE- DATA ON INTERVENTIONS Report by RCHN Foundation in NACHC Community Health Forum, HIT Connections, Fall/Winter 2014

AAPCHO DATA COLLECTION PROTOCOL: THE ENABLING SERVICES ACCOUNTABILITY PROJECT CA CATEGORY CO CODE DE Minut Minutes s Enabling S Services CASE MANAGEMENT ASSESSMENT CM001 Accountability P Project CASE MANAGEMENT TREATMENT AND CM002 (ESAP AP) FACILITATION CASE MANAGEMENT REFERRAL CM003 The he O ONLY s standardized FINANCIAL COUNSELING/ELIGIBILITY FC001 ASSISTANCE data s system t to t track a and HEALTH EDUCATION/SUPPORTIVE HE001 document COUNSELING non-clinical e enabling INTERPRETATION IN001 services t tha hat he help care. OUTREACH OR001 patients a access c TRANSPORTATION TR001 OTHER OT001 21

SAMPLE ENABLING SERVICES EMR TEMPLATE

CONCEPTUAL FRAMEWORK Social D Determinants o of Health O h Outcomes Appropriate C Ap Care Health h ( For example, ideal ( For health condition in question, ( PRAPARE Domains: Race/ outcomes, reduced for example, # of doctor visits, ethnicity, poverty complications, ED visits, exams/tests levels… ) employment, English etc. .) proficiency, etc.. ) Enabling S Services & & o othe her n non-clinical i interventions 23

PRAPARE RESOURCES 24

RESOURCES AVAILABLE NOW ¡ Visit www.nachc.org/prapare ¡ Visit http://enablingservices.aapcho.org § PRAPARE Tool § AAPCHO’s Enabling Services Accountability Project § protocol for data collection of non-clinical § PRAPARE Implementation and Action Toolkit enabling services § Electronic Health Record PRAPARE Templates § Readiness Assessment § Enabling Services Data Collection Implementation Guide § Webinars § PRAPARE Overview § White Papers, Best Practices, Studies § EHR and Workflow-specific Contact Tuyen Tran at ttran@aapcho.org § Frequently Asked Questions § Contact: Michelle Jester at mjester@nachc.org 25

PRAPARE IMPLEMENTATION AND ACTION TOOLKIT 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 26

PRAPARE IS A NATIONAL MOVEMENT! Use and Interest in PRAPARE as of October 2016 • States where health centers are already using PRAPARE (31 states) • States where health centers or PCAs have expressed an interest in PRAPARE (19 states) 27

QUESTIONS AND DISCUSSION 28