SOCIAL DETERMINANTS OF HEALTH Yes, We Have a Role in Our Patient’s Social Determinants of Health
Social Determinants of Health (SDOH) Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Value Driven.Health Care. Solutions. 2
Healthcare Spending as a Percentage of GDP, 2013 https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/ Value Driven.Health Care. Solutions. 3
Select Population Health Outcomes and Risks Factors https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/ Value Driven.Health Care. Solutions. 4
Health and Social Care Spending as Percentage of GDP https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/ Value Driven.Health Care. Solutions. 5
Factors that Impact Health https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/ Value Driven.Health Care. Solutions. 6
6 Key Components of Social Determinants of Health 1.Neighborhood and Built Environment 2.Health and Health Care 3.Social and Community Context 4.Education 5.Economic Stability 6.Food https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/ Value Driven.Health Care. Solutions. 7
Components and Related Social Issues Https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/ Value Driven.Health Care. Solutions. 8
How Social Needs Impact Health Watch this brief video on how social needs can impact health: https://www.youtube.com/watch?v=_11xLlwKgWc Value Driven.Health Care. Solutions. 9
Where to Begin: 1. Know Your Patient Population 2. Know Your Medical Neighborhood 3. Initiate Referrals to Needed Resources/Follow-Up Value Driven.Health Care. Solutions. 10
1. Know Your Patient Population • Assess health care disparities using performance data stratified for vulnerable populations • Use pubic data that is available • Screen for the needs of your patient population • Understand social determinants of health for patients, monitor them at the population level, and implement care interventions based on the data Value Driven.Health Care. Solutions. 11
Public Data Value Driven.Health Care. Solutions. 12
Screening the Needs of Your Patients • Help to determine social issues your patients are facing • Promote a better understanding of your patients • Team effort • EHR Assessment Tool • Paper assessment forms • By asking patients • By using a kiosk • Help patients to understand that screening is completed for all patients in order to optimize their engagement in completing the assessment • Assist patients to understand that your practice is asking these questions as they may have resources to assist them • Educate patients to understand that their health not only depends on their physical care but also on their social and emotional care • Create/develop an assessment tool specific for your patient population Value Driven.Health Care. Solutions. 13
Clinical Domains of an Assessment Tool May Include: • Education • Employment • Housing • Social Integration • Stress • Incarceration • Transportation • Refugee Status • Country of Origin • Safety • Food Value Driven.Health Care. Solutions. 14
Assessment Tools Value Driven.Health Care. Solutions. 15
Examples of Screening Tools Value Driven.Health Care. Solutions. 16
Example Value Driven.Health Care. Solutions. 17
Example Value Driven.Health Care. Solutions. 18
Assessment Tool Resources • Health Leads Social Needs Screening Tool https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/ • Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) http://www.nachc.org/wp-content/uploads/2018/05/PRAPARE_One_Pager_Sept_2016.pdf • IHELP https://sirenetwork.ucsf.edu/tools-resources/mmi/ihelp-pediatric-social-history-tool • AHC Health-Related Social Needs Screening Tool https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf • USDA Food Insecurity Screening Tool https://www.ers.usda.gov/media/8282/short2012.pdf • Hunger Vital Sign http://academicdepartments.musc.edu/ohp/SFSP/FINAL-Hunger-Vital-Sign-2-pager1.pdf • Survey of Well-Being of Children https://www.floatinghospital.org/The-Survey-of-Wellbeing-of-YoungChildren/Overview.aspx. • The HITS (Hurt, Insult, Threaten, and Scream) Screening Tool https://www.baylorhealth.com/PhysiciansLocations/Dallas/SpecialtiesServices/EmergencyCare/Documents/BUMCD- 262_2010_HITS%20survey.pdf Value Driven.Health Care. Solutions. 19
2. Know Your Medical Neighborhood Value Driven.Health Care. Solutions. 20
Community Based Organizations Value Driven.Health Care. Solutions. 21
Some Ideas Of CBO’s To Reach Out To: • YMCAs • Libraries • Housing providers • Faith-based organizations • Community centers • Food pantries and soup kitchens • Neighborhood- or community-specific coalitions • Benefits enrollment site • Organization for individuals who are refugees • Cultural organizations that support a particular population • Youth support organization Value Driven.Health Care. Solutions. 22
Try AuntBertha.com Value Driven.Health Care. Solutions. 23
3. Initiate Referrals and Follow-Up • Refer to CBO by means of your EHR- if capable • Refer by calling the CBO • Provide information for your patient to call the CBO • It is best if the practice/care manager can provide a warm hand off to the organization • Know what forms or information that organization will need and support patient with gathering this • Track the referral • Request that the organization/patient contact you with any updates • Request that the organization contact you if the patient is a no-show • Tap home health, hospitals, respite care, payers services….., for social worker assistance and refer • Many patients that have social needs will also have emotional and behavioral issues as well. Referring these patients to behavioral health may also provide them with social workers that can assist with social determinants and needs Value Driven.Health Care. Solutions. 24
Demonstrating the Impact of Social Needs on Health #1 Juan is a 52-year-old male with complex health conditions. He has Type 2 diabetes and congestive heart failure diagnoses. He recently lost his job after 25 years and is at risk of eviction from his apartment. He frequently visits the emergency department (ED) for a variety of reasons, ranging from chest pain to medication refills. https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/ Value Driven.Health Care. Solutions. 25
#2 Maria is a 26-year-old single mother of two children who works long hours at a restaurant. She lives in a subsidized apartment building with her aging grandmother who has difficulty moving around and rarely leaves the apartment. Many of her neighbor’s smoke and there are reoccurring pest issues in the building. Maria does not have any diagnosed health issues, but her 8-year-old daughter has asthma, which has worsened over the past several months, causing Maria to leave work early a few times to bring her to the ED. https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/ Value Driven.Health Care. Solutions. 26
MENTAL HEALTH Yes, We Have a Role and Responsibility in the Treatment of our Patients Mental Health
Why Do We Want to Focus on Implementing Behavior Health Treatment in Our Practice? • Provider/staff satisfaction for efforts • Decrease in patient noncompliance • Patient satisfaction improvement • Impact on the Total Cost of Care Value Driven.Health Care. Solutions. 28
Costs to Mental Illness & Physical Relationships • Human Cost • Cost to Society • Financial Cost to the Healthcare System Value Driven.Health Care. Solutions. 29
Mental Health Affects Clinical Conditions & Outcomes 29% 68% Adults with a mental Adults with medical health condition also conditions also have mental have medical health conditions conditions Value Driven.Health Care. Solutions. 30
Mental Health Affects Chronic Conditions & Outcomes Value Driven.Health Care. Solutions. 31
Why Target Specific Conditions? Value Driven.Health Care. Solutions. 32
Where to Begin: Practice Readiness • Practice Readiness Assessment • Practice Checklist Value Driven.Health Care. Solutions. 33
Start at the Beginning: Co-located Coordinated Integrated Care Care Care Value Driven.Health Care. Solutions. 34
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