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1
SUPPORTING HEALTH CENTER TRANSFORMATION
WITH SOCIAL DETERMINANTS OF HEALTH
© 2019. 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 Do not publish, copy, or distribute this information in part of whole without written consent from NACHC.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
Deputy Director of Research
National Association of Community Health Centers
2
WHAT ARE SOCIAL
DETERMINANTS OF HEALTH AND
WHY IT IS IMPORTANT TO HAVE
STANDARDIZED DATA ON SDH?
Bay Area regional Health Inequities Initiative (BARHII). 2008. “Health Inequities in the Bay Area”, accessed November 28, 2012 from http://barhii.org/resources/index.html.
Figure 1
WHY COLLECT DATA ON SOCIAL DETERMINANTS OF HEALTH?SDH DRIVE OUTCOMES BEFORE PATIENTS RECEIVE CARE
How well
do we
know our
patients?
Are services
and
community
partnerships
addressing
SDH
available,
adequate,
Integrated,
incentivized,
and
sustainable?
3
SOCIAL DETERMINANTS OF HEALTH DRIVE OUTCOMES &
COSTS
4
5
Business Case for Social Determinants Work
◼ Population Health Management
▪ Risk stratification, segmentation, and adjustment
▪ Re-design care team, enabling services, and community partnerships
◼ Meet Goals of the Quadruple Aim
▪ Improved outcomes—address the root causes of poor health!
▪ Improved patient experience
▪ Improved provider experience
▪ Decreased cost
◼ Demonstrate Health Center Value
◼ Prepare your organization for value based pay
◼ Become leaders in your state to inform social determinant policy and practice
6
Using Social Determinants Data for Population Risk
Segmentation
Source: Oregon Primary Care Association
7
Community Context
Understand Patients
Transform Care
Impact & Value
Reform and Sustainability
Using Social Determinants Data to Accelerate
Transformation and Shift to Value-Based Pay
Root
causes of
poor health
and higher
costs
Under-
stand and
document
root causes
that make
patients
more
complex
New or
improved
interventions/
community
linkages
Better care
management
Empowered
patients
Lower costs
Improve
outcomes
Establish
ROI
Impact root
causes of poor
health
Better
payment and
risk adjustment
Value-driven
care delivery
Integrated
delivery system
Analyze standardized data
Publication pending. Do not quote or
distribute without permission from NACHC,
AAPCHO, and OPCA.
PRAPARE
Why Is It Important for Us to Collect Standardized Patient-
Level Data on the Social Determinants of Health?
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 to deliver patient-centered
care and better allocate limited resources
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
8
System/
Community
level
Payment
Policy level
Publication pending. Do not quote or distribute without permission from NACHC, AAPCHO, and OPCA.
9
WHAT IS PRAPARE AND WHY
SHOULD MY HEALTH CENTER USE
IT?
A national standardized patient risk assessment protocol built into the EHR that wasdesigned to engage patients in assessing & addressing social determinants of health
PRAPARE = SDH screening tool + implementation/action process
What is PRAPARE?
10
Customizable Implementation and Action Approach
Assess Needs Respond to Needs
At the Patient and Population Level
11
Why PRAPARE?
• STANDARDIZED, INTEROPERABLE, and WIDELY USED– Measures Linked with ICD-10 codes and aligned with national initiatves (UDS, ICD-10, IOM, MU, NQF, etc)
– Dominant SDH risk screening tool used by health centers and increasingly used by other organizations (~1,000 orgs)• Hospitals, health systems, ACOs, health plans, population health vendors
• EVIDENCE-BASED and STAKEHOLDER-DRIVEN– Developed and tested by health centers
• PATIENT-CENTERED– Meant to facilitate conversations and build relationships with patients. Standardize the need rather than the question
• WORKFLOW AGNOSTIC– Can fit within existing workflows & be combined with other tools/data (ex: non-clinical staff, clinical staff, self-assessment)
• FREE EHR Templates: – eClinicalWorks, Epic, NextGen, GE Centricity, Greenway Intergy
– Working on Athena, Allscripts
• FREE PRAPARE Implementation and Action Toolkit– Accompanying resources, BPs, & lessons learned to guide users on PRAPARE implementation
Publication pending. Do not quote or distribute without
permission from NACHC, AAPCHO, and OPCA.
HOW WAS PRAPARE DEVELOPED?
12
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
Note: Accountable Healthcare
Communities Tool did not exist in
2014
Publication pending. Do not quote or distribute without
permission from NACHC, AAPCHO, and OPCA.
What Questions Are in PRAPARE?
Find the tool at www.nachc.org/prapare
13
Core
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
Optional Granular
1. Employment: How
many hours worked
per week
3. Insurance: Do you
get insurance through
your job?
2. Employment: # of
jobs worked
4. Social Support: Who
is your support
network?
Publication pending. Do not quote or distribute without permission from NACHC, AAPCHO, and OPCA.
* UDS measures are automatically populated into PRAPARE EHR templates. You do NOT need to ask those questions multiple times!
10 translations of PRAPARE
now available!
14
Crosswalk between PRAPARE and Other National Initiatives
Publication pending. Do not quote or distribute without permission from NACHC, AAPCHO, and OPCA.
15
PRAPARE Coding and Data Dictionary for Enhanced
Interoperability
• Crosswalks including ICD-10,
LOINC, SNOMED codes
• Many PRAPARE EHR
templates have used
crosswalks to map PRAPRAE
measures to ICD-10 codes
• New proposed codes for
PRAPARE responses in
process: ICD-10, LOINC
• PRAPARE Data
Documentation available in
Toolkit
FREE EHR Templates Available*:
NextGen*
eClinical Works
GE Centricity*
Epic
Cerner*
Greenway Intergy
Available for FREE after signing EULA at www.nachc.org/prapare
In development:
Athena—Summer 2019 release
Allscripts
16
PRAPARE EHR TEMPLATES
75% of all health centers
Current 7 + New EHRs =
85-95% of all health centers
* Automatically map to ICD-10 Z codes so you can easily add relevant Z codes to problem or diagnostic list
Excel File Template also available
for health centers not on one of
these EHRs
eCl inicalWorks:
Free configuration guide to build PRAPARE into social history section OR
PRAPARE Smart Form at $1,000 per database. Includes PRAPARE risk tally scoring methodology
Advantages & tradeoffs for each
Greenway Intergy
Need Intergy 11 or higher to capture PRAPARE data
Some data in demographics as usual. Other data in PRAPARE template. Health Choice Network has crosswalk
GE Centr ici ty:
Custom template and Vendor template mapping PMS to EHR
Features:
Data maps to existing data in EHR and PMS (except eCW)
Some templates match to ICD-10 Z codes and added to problem/diagnostics list
Reminder/Alert systems to notify care team member when certain PRAPARE data is due to be collected
WHAT DO I NEED TO KNOW ABOUT THE
PRAPARE EHR TEMPLATES?
Recorded demos of each PRAPARE EHR template available at www.nachc.org/prapare
Available in Chapter 4 of the PRAPARE Implementation and Action Toolkit at www.nachc.org/prapare
18
GREENWAY INTERGY PRAPARE TEMPLATE
19
GREENWAY INTERGY PRAPARE REPORTS
20
Courtesy of
Siouxland Community
Health Center &
AllianceChicago
21
PRAPARE ECW SOCIAL HISTORY NOTES
Instructions available in the
PRAPARE eCW Configuration
guide available in Chapter 4 of
PRAPARE Implementation and
Action Toolkit at
www.nachc.org/prapare
22
PRAPARE ECW SMART FORM
PRAPARE eCW Smart Form
available in Chapter 4 of
PRAPARE Implementation and
Action Toolkit at
www.nachc.org/prapare
Easy to administer
Possible to implement using various workflows and staffing models
Builds patient-provider relationship
Identifies new needs
Leads to positive changes at the patient, health center, and community/pop levels
Facilitates collaboration with community partners
Demonstrates patient complexity23
WHAT WE’VE LEARNED FROM PRAPARE USE
Publication pending. Do not quote or distribute without permission from NACHC, AAPCHO, and OPCA.
24
HIGH RISK PATIENTS FACE MORE SOCIAL DETERMINANT
RISKS THAN GENERAL POPULATION
0%
5%
10%
15%
20%
25%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Pe
rce
nta
ge
of
Pa
tie
nts
Tally Scores
Publication pending. Do not quote or distribute without permission from NACHC, AAPCHO, and OPCA.
High Risk Total
(N= 2,679)
General Pop Total
(N = 4,432)
Overall Total
(N = 7,111)
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
(enabling services, mobile outreach,
children’s book corner, food banks,
clothing closets, wellness center,
transportation shuttle, etc)
Build partnerships with local organizations
(transportation partnerships)
Use for Population Segmentation/Risk
Stratification
Inform health delivery redesign (ex:
Medicaid and Medicare ACO discussions)
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
25
Guide work of local foundations (ex: New York
housing)
Publication pending. Do not quote or distribute without permission from NACHC, AAPCHO, and OPCA.
Calculate ROI for social determinant
interventions and revenue generated from
reducing no-show rates
◼ 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
26
PRAPARE IMPLEMENTATION & ACTION TOOLKIT
http://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
Plus:
Readiness
Assessments
Best Practices
Webinars
FAQs
Translations
and more
27
HOW DO WE COLLECT SENSITIVE
SOCIAL DETERMINANTS DATA?
28
Sample Workflow Models for PRAPARE Data Collection
Who Where When How Rationale
Non-clinical staff
(patient navigator,
community health
workers)
In waiting
room or in
staff office
Before of after provider
visit
Administered PRAPARE
with patients who would be
waiting 30+ mins for provider
Provided enough time to discuss SDH needs.
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.
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
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
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
Patient Self-
Assessment
At home, in
waiting room,
etc.
Before visit with provider Self-administered using
email, tablets, kiosks, etc.
Low burden on staff to collect data. Privacy for
patient to complete assessment. Utilize time
when patient would otherwise be waiting. Staff
time can be used to discuss results with patients
to address needs.
Publication pending. Do not quote or distribute without permission from NACHC.
◼ Empathic Inquiry: combines methods of motivational interviewing and trauma-informed care to
promote partnership, trust, affirmation, engagement, and respect
◼ Shift mindset from “collecting data” to “getting to know your population—one person at a time”
◼ Explain why you are collecting this information, how it will be used, and options for follow-up
◼ One person’s data is another person’s difficult life experiences, so it’s important to emphasize:
29
Collecting Sensitive Social Determinants Data Using
Empathic Inquiry
SensitivityPatient
EngagementCompassion
Patient
Engagement
Privacy
Patient
Autonomy
Patient
Priorities
Strengths,
Assets,
Interests
Minimize
patient
distress
Avoid
stigma
1) Start with relationship and engagement
▪ Introduce yourself and explain the what, why, and how long of screening process
▪ Ask for permission to have conversation, acknowledge sensitivity of questions, and give permission to
decline at any moment
2) Empathize to create and convey understanding
▪ Ask about patient’s priorities, interests, experiences, and perspectives on experiences
▪ Convey understanding through attentive non-verbal cues and through reflective listening “Sounds like
you’re tired of bouncing around between housing situations.” or “Getting help with your phone bill
sounds like your highest priority”
3) Support by focusing on strengths
▪ Provide affirmations of patient’s strength and resilience “Sounds like you’ve been working hard to
make ends meet. You are clearly very resourceful and creative”. “It takes a lot of strength to get
through such a tough situation. You really have a lot of grit.”
4) Summarize and plan for action and collaboration
▪ Ask if patient wants referrals to other team members or community resources
5) End with empathy 30
Key Steps for Empathic Inquiry Conversation
Source: “Patient-Centered Social Determinants of Health Screening Conversation Guide” by the Oregon Primary Care Association.
◼ By Waianae Coast Comprehensive Health Center in Hawaii
https://www.youtube.com/watch?v=iQjJ_QsDvmI&list=PLvoNbrkrX4YRsfMJz3qJMGrwZGCWPf
sqE&index=3&t=2s
31
Video Demonstrating Effectiveness and Appropriateness
of Empathic Inquiry Approach
◼ Make patients feel comfortable. Talk normally to them to have a conversation
◼ Create safe, non-judgmental space. Don’t react to any of their answers
◼ Let them know you’re here to help
◼ If patient doesn’t want to speak, tell them they can just nod their head “yes” or “no”
◼ Don’t force resources on them but let them know about them and that you’re happy to talk about
them later if they want to reach out
32
Best Practices for Understanding Needs of Patients
When Not Actively Expressed
◼ Deep-dive into workflow models to collect social determinants of health data in clinic workflow
◼ Best practices for building capacity to respond to social determinant of health needs
◼ Aligning work across the Dakotas for interoperability
◼ Tips for getting started
◼ Strategies for sustaining work on social determinants when don’t have extra funding
◼ Draft implementation plans
◼ Troubleshoot challenges33
October In-Person Training
34
For More Information on PRAPARE
Visit
www.nachc.org/prapare
Join our listserv!
Email [email protected]
Email Michelle Jester at
Resources Available to Support
Health Centers, PCAs, & HCCNs
PRAPARE Implementation and Action Toolkit
Free EHR templates for Cerner, eCW, Epic, GE
Centricity, Greenway, NextGen
PRAPARE Readiness Assessments for CHCs &
PCAs
Recorded Webinars on PRAPARE, Workflows,
EHR Templates, etc.
PCA/HCCN Case Studies
10 translations of PRAPARE including Spanish,
Somali, Arabic, Chinese, Tagalog, Korean,
Vietnamese, and more!
35
Questions & Discussion
For more information, visit www.nachc.org/prapare
To receive the latest updates on PRAPARE, join our listserv!
Email Michelle Jester at [email protected].