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This project was made

possible with funding from:

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GETTING STARTED IN USING PRAPARE

TO ASSESS AND ADDRESS THE

SOCIAL DETERMINANTS OF HEALTH

© 2017. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary

Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use by NACHC, its partners, and

authorized recipients. Do not publish, copy, or distribute this information in part of whole without written consent from NACHC.

Michelle Jester, Research Manager

National Association of Community Health Centers

Lynn Gonzalez, Associate Director of Behavioral Health

Open Door Family Medical Centers

Massachusetts League of Community Health Centers CHI Conference

May 3, 2017

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AGENDA

Topic Timing

Overview of PRAPARE 15 mins

Strategizing Implementation: Lessons from Early Adopters 10 mins

Health Center Example: Open Door Family Medical Center 20 mins

Q&A 20 mins

Challenges Activity 15 mins

Q&A 10 mins

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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

WHAT IS PRAPARE?

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Customizable Implementation and Action Approach

Assess Needs Respond to NeedsAt the Patient and Population Level

PRAPARE WAS DESIGNED TO LEAD TO SYSTEMIC CHANGE

Patient and Family

Care Team Members

Health Center

Community/Local

Health System

State and National

Policies

Individual

level

Organizational

level

Payer level

Empowered to improve health and wellbeing

Better manage patient and population needs

Design care teams and services to deliver

patient/community-centered care

Integrate care through cross-sector partnerships,

develop community-level redesign strategy for

prevention, and advocate to change local policies

Execute payment models that sustain value-

based care (incentivize the social risk

interventions and partnerships, risk adjustment)

Ensure capacity for serving complex patients,

including uninsured patients

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System/

Community

level

Payment

Policy level

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TIMELINE OF THE PROJECT

Year 1

2014

•Develop PRAPARE tool

Year 2

2015

•Pilot PRAPARE implementation in EHR and explore data utility

Year 3

2016

•PRAPARE Implementation & Action Toolkit

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Dis

se

min

atio

n

DEVELOPING PRAPARE

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Identified 16 Core Social Determinants of Health

Sensitivity

Burden of Data

Collection

Action-ability

Aligned with National

Initiatives:

* Healthy People 2020

* ICD-10

* Meaningful Use Stage 3

* NQF on Risk Adjustment

Literature Review

Experience of Existing

ProtocolsStakeholder Feedback

Criteria

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PRAPARE DOMAINS

Spanish and Chinese

(Mandarin) translated versions

Find the tool at:

www.nachc.org/prapare

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Core

UDS SDH Domains Non-UDS SDH Domains

(MU-3)

1. Race 10. Education

2. Ethnicity 11. Employment

3. Veteran Status 12. Material Security

4. Farmworker Status 13. Social Isolation

5. English Proficiency 14. Stress

6. Income 15. Transportation

7. Insurance 16. Housing Stability

8. Neighborhood

9. Housing Status

Optional

1. Incarceration

History

3. Domestic Violence

2. Safety 4. Refugee Status

Currently available:

NextGen

eClinicalWorks

GE Centricity

Epic

Available for free after

signing EULA at

www.nachc.org/prapare

In development:

Greenway Success EHS (summer 2017)

Greenway Intergy

Allscripts (late 2017)

Meditab (late 2017)

Athena

Cerner

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PRAPARE EHR TEMPLATES

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▪ EHR Builds:

▪ NextGen: Built into base in as stand-alone template. Compatible with latest KBM.

▪ Tablets/Kiosks Build available from Otech at $1,500 per configuration or with NextGen NextPen

▪ Reporting Tools from OSIS

▪ eCW: Smart Form available for $1,000 per database.

▪ Centricity: Custom Template & Vendor Template that maps PMS to EHR

▪ Epic: OCHIN Epic and Epic PRAPARE

▪ Data maps to existing data in EHR and PMS (except eCW)

▪ Some templates match to ICD-10 Z codes and added to problem list

▪ EHR templates have reporting capabilities and tools to extract, export, and aggregate data

▪ NextGen Reporting Tool

▪ eCW: structured data, BridgIT 9

EHR TEMPLATE FUNCTIONALITIES

Courtesy of

Siouxland Community

Health Center &

AllianceChicago

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16 core domains that have been standardized

All align with national initiatives (HP2020, UDS, IOM, MU, NQF, etc)

Design

Vetted and stakeholder engaged development process

In the EHR to facilitate assessment & interventions (free templates)

Conversation starter and patient-centered

Common core yet flexible:

Able to make more granular and/or add questions

Focus on standardizing the need, not question

Can be used in combination with other tools/data

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WHAT MAKES PRAPARE UNIQUE AND FEASIBLE?

Health Centers in 44 states are already using PRAPARE EHR

templates

Interest from CHCs in every state

Most PCAs and HCCNs

Some hospitals and health systems

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PRAPARE IS A NATIONAL MOVEMENT!

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What We Learned

www.nachc.org/prapare

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PILOT RESULTS

Easy to administer

Builds patient-provider relationship

Identifies new needs

Many patients face between 4 – 7 social determinants of health

Positive correlation between number of social determinants and

likelihood of having hypertension

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HOW PRAPARE DATA HAS BEEN USED TO IMPROVE CARE

DELIVERY AND HEALTH OUTCOMES

Ensure prescriptions and treatment plan

match patient’s socioeconomic situation (all)

Build new or expand existing services in-

house for same-day use as clinic visit

(children’s book corner, food banks,

clothing closets, wellness center,

transportation shuttle, etc)

Build partnerships with local organizations

(ex: Iowa and NY transportation)

Create risk score to identify complex

patients (ex: Hawaii, NY, OR)

Inform health delivery redesign (ex:

Medicaid and Medicare ACO discussions in

Iowa, New York)

INDIVIDUAL Level

POPULATION Level

System and

Policy Level

Streamline care management plans for better

resource allocation (ex: Hawaii)

Use data for “seat at the table” with payers to

discuss sustainable payment and APM (all)

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Guide work of local foundations (ex: New York

housing)

◼ 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

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PRAPARE IMPLEMENTATION & ACTION TOOLKIT

www.nachc.org/prapare

◼ Chapter 8: Build Capacity to Respond to SDH Data

◼ Chapter 9: Respond to SDH Data with Interventions

◼ Chapter 10: Track Enabling Services

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Getting Started:

Deep Dive into Implementation

www.nachc.org/prapare

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1) Right information:

Review PRAPARE

questions and response

choices

Which ones are already

collected/documented?

5 RIGHTS/CDS PILOT SITE EXAMPLE

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5 RIGHTS/CDS EXAMPLE IN DETERMINING

IMPLEMENTATION OF PRAPARE TOOL

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2) Right people- who

Who will collect it?

Who will need to see it to inform care?

Who will respond to needs identified?

3) Right channels- where

Where are we collecting this information?

Where do we need to display and share this information (team huddles, etc.)?

4) Right format- modality

How are we collecting the information and in what manner are we collecting it?

5) Right time- When?

Collecting it at the right time in staff and patients’ workflow

SAMPLE DATA COLLECTION WORKFLOWSHealth

CenterWho 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 their situation.

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

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www.nachc.org/prapare

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PLANNING FOR RESPONSES

TO NEEDS IDENTIFIED

USING 5 RIGHTS/CDS TO PLAN FOR RESPONSES

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5 Rights Responses/Interventions

What/Information Comprehensive list of resources & referral list for needs

Who Given to patient by person administering the PRAPARE questionnaire.

[Note: AmeriCorps staff to keep resource list up to date]

How/Format Searchable database of resources; Printed resources in 3-ring binder

Where/Channels On employees intranet; placed in provider’s hallway, front desk

When/Workflow Resources will be given immediately to patient once need is identified;

referral to appropriate staff will be made after patient sees provider

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BUILDING CAPACITY TO RESPOND

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IN HOUSE OR PARTNERSHIPS?

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HEALTH CENTER EXAMPLE:

OPEN DOOR FAMILY MEDICAL CENTER

PRAPARE Implementation -Open Door Family Medical Centers

Objectives:• Open Door Family Medical Centers History

• Patient Population

• Why PRAPARE?

• Data Gathered

• Next Steps

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Open Door Family Medical Centers

Founded in the basement of a church in 1972

Originally staffed by volunteer Doctors and Nurses

Gained Federally-Qualified Health Center recognition and Section 330 funding

External Accreditation

Joint Commission & NCQA

JCAHO since 1998

Keen focus on patient safety, staff competency, led to enhanced Quality Improvement

capabilities

NCQA PCMH Level 3 since 2009

Importance of patient access and primary care provider empanelment; focus on

transitions of care and care coordination

DRP NCQA Recognition since 2012

Evidence-based care of patients with diabetes emphasized

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Open Door ServicesLicensed under Department of Health

Article 28

• 6 Primary Care Sites in Two Counties

• 7 School-based Health Centers

• Mobile Dental Vans

• Family Medicine Residency program

• Dental Residency program

Open Door Family Medical Centers

At the end of 2016, we had:

• Over 100 Medical, Behavioral Health, and Dental clinicians providing care to…

• 50,000+ patients in…

• 280,000+ visits

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Target Population

•Low income (200% or Below Poverty Level)Note: According to the new 2016 Federal Poverty Guidelines, income of $24,300/household of 4

is considered at 100% poverty level.

•Uninsured

•Underserved

•High Risk Population

•Women of Child Bearing Age

•Families and Children

Income as a Percent of Poverty LevelAbout 87% of Open Door patients fall into 200% or below poverty level.

Note: According to the 2016 Federal Poverty Guidelines, income of $24,300/household of 4 is considered at 100% poverty level

100% and Below

101-150%

151-200%

Over 200%

Unknown

Income of $24,300/

household of 4

Income of

$36,450

household of 4

66%

16%

5%11%

2%

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Principal Third Party Medical Insurance Source

39%

Open Door Patients in 2016

Uninsured

Medicaid

CHIP

Medicare

Private

43%

35%

5%

4%13%

Why Now?

• We have evolved from saying “non-compliant” to “non-adherent”

• We need to evolve from saying “non-adherent”, to “what may I be missing about my patient?”

• To take better care of our toughest medical patients, often the key is to uncover and address the underlying BH and social determinants of health issues.

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Addressing the Gap

• Consultation model for psychosocial issues on the medical units

– Behavioral Health Integration Specialist (BHIS)

– Licensed Clinician (LMSW)

– Embedded, full-time member of the primary care team

– BHIS patient interactions are not billed (not reimbursable)

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Initial Foray into Gathering SDHPilot to Purpose:

• Screening for needs

• Assessing patients Holistically & Ecologically

• Gathering Social History

• Pilot Project in 2015- PRAPARE questions embedded in the EMR (Social History)

• PRAPARE entered into EHR as a SMART form in January, 2017

Who is Doing PRAPARE?

Behavioral Health Integration Specialist (BHIS)

• Clinicians Embedded in the medical units

• LMSW- Licensed Masters Social Worker

• Perform BH assessments and link patients to BH care

• Meet with patients in exam rooms before or after provider enters

• BHIS screens patient because of a previously documented unmet health concern, previous BH involvement, or new patient to Open Door

• Provider identifies a BH concern and calls in BHIS

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• Patient Advocates

• Staff Bachelor level support

• In proximity to medical units

• Access (identify needs, health insurance, Wellness program)

• Health literacy (Chronic Disease Management Education)

• Medication compliance (Pharmacy Assistance Programs, review visit summaries, etc.)

• Treatment/appointment adherence

PRAPARE DATA• 3,750 surveys done from 7/1/15 – present

• 60% done by Behavioral Health Integration Specialists (BHIS)• 30% done by Patient Advocates• 10% clinical providers

• 69% born outside of U.S.

• 76% of respondents speak Spanish as primary language

• 27% of respondents say they are “quite a bit, somewhat, or very much stressed”

• 39% have less than a high school degree

• 19% reported going without food, clothing, utilities, childcare, medicine/medical care when it was really needed

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Challenges

• Questionnaire can become a lengthy conversation- this takes time

• Engagement is Key for eliciting robust responses

• Staffing Shortages• Lack of Resources for the uninsured

population• Tracking Referrals/Follow-up

Next Steps

• Evaluate data• Establish strong ties to CBO’s• Establish culturally sensitive

practices based on PRAPARE data

• Spanish version of PRAPARE• Establish screening goals

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Thank You!

Lynn Gonzalez, LCSW

Associate Director of

Behavioral Health

(914) 502-1482

lgonzalez@odfmc.org

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QUESTIONS AND DISCUSSION

For more information, visit www.nachc.org/prapare

To receive the latest updates on PRAPARE, join our listserv!

Email Michelle Jester at mjester@nachc.org.

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GETTING STARTED

Medicaid (2703 Health Homes, etc.)

Private Foundation Grants

Cooperative Agreement

Aligning with other state initiatives (payment reform, delivery system

transformation, quality, etc.)

Just doing it!

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STATE MODELS FOR IMPLEMENTING PRAPARE

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◼We invited clinics to pick a patient population and interview 10

consumers using 3 questions from PRAPARE

◼Afterwards, clinics met face-to-face to share their experiences

How did you and the patient discuss these questions?

What did you observe about the process (your experience, patient’s

reaction)?

Did asking these questions lead to conversations about other topics?

Starting Small: Experimenting with PRAPARE in Oregon

APCM Clinics

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Visit www.nachc.org/prapare

PRAPARE Tool

PRAPARE Implementation and Action Toolkit

Electronic Health Record PRAPARE Templates

Readiness Assessment

Webinars

PRAPARE Overview

EHR and Workflow-specific

Frequently Asked Questions

Contact: Michelle Jester at mjester@nachc.org

Visit http://enablingservices.aapcho.org

AAPCHO’s Enabling Services Accountability

Project

protocol for data collection of non-clinical

enabling services

Enabling Services Data Collection

Implementation Guide and Best Practices

Contact Tuyen Tran at ttran@aapcho.org

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RESOURCES AVAILABLE NOW

Upcoming Opportunities:

* Train the Trainer Academy

* CHC Engagement Grants

* Resources from State Pilots

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CHALLENGES ACTIVITY

◼ Think about what challenges you anticipate facing as you implement PRAPARE

◼ Volunteers will present their challenges to the group

◼ We’ll use the collective brainpower of the group to troubleshoot these challenges

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Challenges and Overcoming Challenges

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QUESTIONS AND DISCUSSION

For more information, visit www.nachc.org/prapare

To receive the latest updates on PRAPARE, join our listserv!

Email Michelle Jester at mjester@nachc.org.

◼ What other activities could PRAPARE leverage and/or add value to? Does this affect or inform the workflow model?

◼ What will the population of focus be? How does that affect the workflow model?

◼ Who will be involved in the implementation of PRAPARE? ▪ Data collection, input data, exporting data, responding to needs identified

◼ Where and when will data be collected and needs responded to?

◼ What modality will be used to collect PRAPARE data and respond to needs identified? ▪ In-person with staff or self-assessment through tablets, kiosks, patient-portal, paper, etc.

◼ What resources are available to respond to needs identified?

◼ Develop plans and process for using the data for enhanced clinical care, complexity analyses, and advocacy for more effective payment.

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Aspects to Consider When Strategizing Implementation Plans