A 2 year demonstration project in Providence Oregon Family Medicine Residency Clinics to connect vulnerable families directly to community support services: the Patient Centered Medical Home/Community Connection

Health Care TransformationFlexible Services

AKA - Air Conditioner Bill

What are flexible services?Flexible services are health related non-State plan services intended to improve care delivery and member health. They are cost effective alternatives to traditional services.

Must Support the Following: Examples:

Achieving Treatment Goal

Preventing Decompensation

Diverting From Higher Level of Care

Assisting in Environmental Stability

Managing a Chronic Condition

Small RefrigeratorShoesTemporary housing/utility assistanceFood AssistanceCertain CM/Pt. Navigation supportsScales or BP Monitor for homeSupport Groups/Wellness activities

Health Care TransformationNew Workforce

Oregon’s health system transformation and the federal Affordable Care Act have emphasized the essential role of nontraditional health workers in promoting health and delivering care. Under new legislation, Medicaid dollars can be used towards funding these positions

In Development

1. Must work under the supervision of licensed HC providers 2. State approved curriculum & certification process 3. Registry will be in place

In Development

1. Must work under the supervision of licensed HC providers 2. State approved curriculum & certification process 3. Registry will be in place

Community Health Worker Peer Wellness Specialists Personal Health Navigator Doula Peer Support Specialists (MH

and Addictions)

Providence CaregiversSurveyed in 2013

Over 500 Providers, Nurses, Care Managers and Social Workers responded

Themes •Conditions of poverty impact our patient's ability to follow through with care plans and discharge plans (63% reported this as true for the majority of their low income patients)

•Staff and providers want more direct pathways/partnerships with social service partners

•"A community social service provider housed at my clinic or hospital" would be extremely or very helpful (Top ranked potential new resource)

PartnersInternal and Community

ProvidenceMilwaukie HospitalMilwaukie FoundationFamily Medicine Residency Program

PMG SE/PMG Milwaukie

Community Health Div.

CORE

ProvidenceMilwaukie HospitalMilwaukie FoundationFamily Medicine Residency Program

PMG SE/PMG Milwaukie

Community Health Div.

CORE

Community PartnersOR Food BankChildhood Hunger CoalitionProject Access NOWFamilias en AcciónImpact NW

Community PartnersOR Food BankChildhood Hunger CoalitionProject Access NOWFamilias en AcciónImpact NW

Project DesignProvidence

6

Who: Families with children ages 0-18

When: Every Well-Child Exam

How: Self-administered questionnaire while being roomed by the medical assistant

Resources for all families screening positive:1.Direct connection to a Patient Navigator2.Local food pantries and food security programs embedded in the AVS

Three Major Components

1.Screening 2.Direct connection to resources for those experiencing hunger and/or food insecurity 3.Standard protocol, coding & documentation in EMR for those screening positive

Milwaukie Clinic SE Clinic

Total Patients = 5,900 Total Patients = 5,700

23% on Medicaid 40% on Medicaid

8% Uninsured 8% Uninsured

Roughly 2,000 patients Roughly 2,800 patients

Estimated Patients Vulnerable to Food Insecurity

Financial Support

9

Program Evaluation Component

Children & Families Staff and Providers Change in Food Security Status Awareness of the issue and its

importance

Knowledge of community resources

Comfort levels with addressing this issue

Confirmed connection to programs and resources – Food, early childhood, dental, Soc. Serv.

Equipped with tools and knowledge needed to address the issue

Impact on depression & anxiety

Impact on parental level of distress

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Community Partner is reimbursed based on outcomes with Project Access NOW administering

Pay Points

Initial assessment completed – Identify needs and Pathways

Education, information & referral, appointments set

Pathways completed – Confirmed connection to services and completion of goals

PANOW Web based system generates reporting and tracks outcomes

Community Partner is reimbursed based on outcomes with Project Access NOW administering

Pay Points

Initial assessment completed – Identify needs and Pathways

Education, information & referral, appointments set

Pathways completed – Confirmed connection to services and completion of goals

PANOW Web based system generates reporting and tracks outcomes

Pathways NavigatorsTesting a new model of reimbursement

Screen and Intervene: Success is in the Details

• Staff and Provider Survey prior to training• Training: 36 Clinic staff at 2 clinics trained in two 45

minute sessions over lunch26 Faculty/Resident and Advance Practice

Providers trained. Training incorporated into afternoon didactics: CBL on FTT and Childhood Obesity

Clinic and Provider Workflows

• Medical Assistant Role in Screening and Documentation

• Provider Role in addressing need and encouraging referrals to Patient Navigator

• Referral Workflows to PANOW and scheduling appointments. Bus tickets available.

• Follow up reminder calls to families• Navigator communication back to clinics PRN

Retrieving Data from the EMR

• Where and how to document to be able to pull data

• Build EMR report to pull data monthly and report quarterly

• You need a good analyst to build your reports• Data: Opportunities to screen by provider

(WCC), Total number screened (V code in problem list), Total positive screens ICD9 994.2

More Data

• Demographic Information: address and zip codes to identify neighborhood pockets of need, language, insurance type, age

• Number of referrals to PANOW generated compared to number enrolled in Pathways.

• Number of completed Pathways• What are the most prevalent social service

needs of these families beyond food?

Can’t Forget

• Physician Champions in each clinic• IRB: waivers or expedited review/exemption request• $$$$$$$$$$$$Access to a good grant writerFinancial support from sponsoring hospital

foundation if you can generate interestFundraising

Evaluate

• Impact of training on staff/provider knowledge and comfort levels. Survey again at 8 – 10 months into pilot.

• Impact on family of Pathway interventions: parental depression/anxiety, level of distress in family, ability to seek out and access resources. Enrollment and discharge surveys

• 2 point of care surveys in the clinics: comfort with screening and effectiveness of resources

Evaluate and Disseminate Findings

• Is this spreadable to other clinics within the medical group across the state?

• Is it cost effective? Sustainable?• Were families comfortable with being

screened and satisfied with resources offered?• Did staff and provider comfort and satisfaction

with screening change from baseline?• Publish. Present. Share our experience

References

• Edwards, M. Who is Vulnerable to Hunger in Oregon? Rural Studies Program Fact Sheet, January 2010. Available at: http://ruralstudies.oregonstate.edu/fact-sheets

• Hoisington AT, Braverman MT, Hargunani DE, Adams EJ, Alto CL. Health care providers’ attention to food insecurity in households with children. Preventive Medicine. 2012. Available at: http://linkinghub.elsevier.com/retrieve/pii/S0091743512002551

• Accessed July 12, 2012. • Hager ER, Quigg AM, Black MM, et al. Development and Validity of a 2-Item Screen

to Identify Families at Risk for Food Insecurity. Pediatrics, 2010; 126: e26-e32. • Burkhardt, Beck, Conway, et al. Enhancing Accurate Identification of Food

Insecurity Using Quality Improvement Techniques. Available at http://pediatrics.aappublications.org/content/early/2012/01/11/peds.2011-1153

• Klass, Perri. Poverty as a Childhood Disease Available at http://well.blogs.nytimes.com/2013/05/13/poverty-as-a-childhood-disease/?smid=tw-share...

• Thanks for your interest!• More questions?

charlotte.navarre@providence.org