Addressing Individual Whole Health as Population Health: a social determinants of health strategy Rachel Smith, MPH Providence Health & Services October 9, 2017
Providence Health & Services is a faith-based multi-state not-for-profit health system representing 50 hospitals and 829 clinics Providence has serving Oregon for 160 years with our 8 acute care hospitals, over 100 clinics and a regional health plan. Focused on a singular commitment to improve the health of everyone in our communities, especially those who are poor and vulnerable 2
What is a Community Resource Desk? 3
Services and Workflows 4
Who staffs the Community Resource Desk? • Serves : Clatsop County community Serves : the Quad-county Portland • Mission : help people meet housing, metro area food and other basic living needs Mission : help people prosper through • Programs : a community of support • Food Programs : • Housing and utilities Early childhood • Support: child care, clothing, Youth and family services counseling, education and employment Seniors and People with Disabilities Housing and Safety Net Services 5
Who does the CRD serve? Race/Ethnicity Primary Language Average Age 48 Gender 77% English 18% Spanish 5% Other 62% 6% 32% 6
Initial Outcomes Clients Served # Clients 4,463 Individuals benefiting (based on HH size) # Adults and children 10,086 % Federal Poverty Level Insurance Type 35% Income not given 30% 30% 26% >150% 24% 25% 126-150% 20% 101-125% 15% 76-100% 10% 8% 6% 6% 51-75% 5% 0% 1-50% Medicaid Medicare Uninsured Private - Private - Other Unknown Providence 0% 0% 5% 10% 15% 20% 25% 30% 7
Initial Outcomes – Resource Needs Types of need (clients can be served in more than one area) 700 661 631 600 500 409 400 353 342 300 247 242 228 200 164 133 119 75 100 55 33 25 0 8
Client Feedback “This was life -changing for “I had about given up me, I was able to prevent “I wish more social before I went to the eviction due to the rental service type agencies Resource Desk. They assistance I received. I treated people like really plugged me into went back to the desk for people.” the services I the resource list and have needed.” been sharing it with others.” 9
Provider Feedback “I finally feel empowered to focus on medicine because I’m confident that I have somebody more expert Do you currently feel equipped with the than myself and our overwhelmed knowledge and tools needed to help social workers who is able to find vulnerable patients' access SDH resources? SIREN NEXT resources for our patients.” 60% 48% 50% 41% 34% 40% 30% “It makes me feel like there is more trust in 30% 19% the relationship and they [the patients] 15% 20% 7% have a feeling that I’m meeting them 6% 10% where they are and I’m understanding the 0% Very Equipped Moderately Equipped Somewhat Equipped Not Equipped at All things that they are most concerned about May 2015 (n=54) Jan 2016 (n=32) as opposed to just addressing what I want to address like childhood developmental milestones.” 10
Working Together Across Sectors 11
Lessons Learned To maximize our resource specialists talents the program can serve more than one primary care clinic Hiring the right staff is crucial Having strong advocates and champions is essential to success Integrating new workflows into teams can be a slow process Community partnerships can be extremely beneficial, but difficult from a legal and compliance standpoint More seniors utilize the program than we initially projected Clients appreciate our 7-day and 30-day follow-up calls 12
Next Steps Integrating the CRD in our Electronic Health Record Evaluation work focused on health outcomes and cost utilization Looking at expand to additional Providence service areas in 2018 Standardize and expand social determinant screening within Providence 13
Contact me for more information: Rachel Smith rachel.smith@providence.org 503-893-6353 14
Recommend
More recommend
