OF HEALTH DATA USING PRAPARE This project was made possible with - - PDF document

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This project was made possible with funding from:

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COLLECTING SOCIAL DETERMINANTS OF HEALTH DATA USING PRAPARE TO REDUCE DISPARITIES, IMPROVE OUTCOMES, AND TRANSFORM CARE

WEBINAR AGENDA

Topic Facilita tator

• rs

Minutes Importance of Collecting Data on the SDH

Michelle Proser, NACHC 15 mins

How We Created PRAPARE

Michelle Jester, NACHC 10 mins

Status of PRAPARE and How You Can Use PRAPARE at Your Health Center

Alicia Atalla-Mei, OPCA 10 mins

What We’ve Learned

Rosy Chang Weir, AAPCHO 15 mins

Using Data on the SDH

Michelle Jester, NACHC and Tuyen Tran, AAPCHO 15 mins

Next Steps and Q&A

Michelle Proser, NACHC 25 mins

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WHY IS IT IMPORTANT TO COLLECT STANDARDIZED DATA ON THE SOCIAL DETERMINANTS OF HEALTH?

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Under value-based pay environment, providers are held accountable for costs and outcomes Difficult to improve health & wellbeing and deliver value unless we address barriers Current payment systems do not incentivize approaching health holistically and in an integrated fashion

• Providers serving complex patients often penalized without risk

adjustment

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HEALTH, ACCOUNTABILITY & VALUE

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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

WHAT IS DRIVING THE NEED TO COLLECT DATA ON THE SOCIAL DETERMINANTS OF HEALTH (SDH)?

How well do we know our patients? Are services addressing SDH incentivized and sustainable? Are community partnerships adequate and integrated?

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Social and Economic Factors (40%) Clinical Care (20%) Health Behaviors (30%) Physical Environment (10%)

Project Goal: To create, implement/pilot test, and promote a national standardized patient risk assessment protocol to assess and address patients’ social determinants of health (SDH). PRAPARE: PROTOCOL FOR RESPONDING TO & ASSESSING PATIENT ASSETS, RISKS, & EXPERIENCES

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PRAPAR ARE

Assessm ssment t Tool To Identi tify Needs Protoco col to to Respond to to Needs

• Paper Tool
• EHR Templates
• List of Granular

Needs

• ICD-10 Z Codes
• Workflow Diagrams
• Staff Training

Curriculum

• Implementation and

Action Toolkit

• Examples of Interventions
• Guidance on how to build

capacity

• Appendix of Resources
• Guidance on informing

policy and payment

+

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Commun unity Context Understand and Patient nts Trans nsfor form m Care Impact Demons nstrat ate Value

FROM DATA TO PAYMENT: CONNECTING THE DOTS

Upstream socio- ecological factors impact behaviors, access,

• utcomes,

and costs Inquiry & standardized data collection Under- stand extent

• f patient &

population complexity New or improved non-clinical interventions, enabling services, and community linkages Impact root causes

• f poor

health Improve

• utcomes,

patient/staff experiences

Lower total

cost of care Negotiate for payment change Ensure sustainability

• f

interventions

Analyze stand ndar ardized data

Individual Patient Level Local Population Level State and National Level

HOW DID WE CREATE PRAPARE?

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Used evidence to apply domain criteria

Literature reviews of SDH associations with cost and health

• utcomes

Monitored and/or aligned with national initiatives

• HP2020
• RWJF County Health Rankings
• ICD-10
• IOM on SDH in MU Stage 3
• NQF on SDH Risk Adjustment

Collected existing protocols from the field

• Collected 50 protocols (many not

validated)

• Interviewed 20 protocols
• Identified top 5 protocols

Engaged stakeholders for feedback

• Braintrust (advisory board) discussion
• Surveyed stakeholders
• Distributed worksheet to potential users

for feedback

Identified 15 Core Domains

IDENTIFYING CORE DOMAINS

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Critiera: 1) Actionability 2) Alignment with National Initiatives 3) Evidence in Research 4) Burden of Data Collection 5) Sensitivity 6) Stakeholder Feedback

PRAPARE DOMAINS

PRAPARE asks 15 questions to assess 14 core SDH domains.  9 domains already asked for federal health center reporting (Uniform Data System) so can be auto-populated  5 non-UDS domains informed by Meaningful Use Stage 3 PRAPARE has 6 optional domains. Find the tool at : http://www.nachc.com/research-data.cfm

UDS SDH Domains

• 1. Race
• 2. Ethnicity
• 3. Veteran Status
• 4. Farmworker Status
• 5. English Proficiency
• 6. Income
• 7. Insurance
• 8. Neighborhood
• 9. Housing

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Core Non-UDS SDH Domains

• 10. Education
• 11. Employment
• 12. Material Security
• 13. Social Integration
• 14. Stress

Optional Non-UDS SDH Domains

• 1. Incarceration History
• 2. Transportation
• 3. Refugee Status
• 4. Country of Origin
• 5. Safety
• 6. Domestic Violence

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CROSSWALK OF PRAPARE WITH OTHER NATIONAL INITIATIVES

PRAPAR ARE Domain UDS ICD-10 10 IOM Meaningf gful Use (2 and 3) HP202 020 RWJF County ty Health th Race/Ethnicity X X X X X Farmworker Status X Veteran Status X Seeking comments English Proficiency X X X X Income X X X X X Insurance Status X X X Neighborhood X X X X X Housing X X X Education X X X X X Employment X X X X X Material Security X X X X X Social Integration X X X X X Stress X X X X Selected questions to measure SDH domains

• Pulled from

existing validated questions when possible (few validated questions exist)

Questions Reviewed by Health Literacy Expert

• To ensure

language matched common reading levels

Performed Cognitive Testing on Questions

• Each pilot site

performed cognitive testing with at least 10 patients

Pilot Tested Questions

• Revised as

necessary after pilot testing

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VALIDATING THE TOOL

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EXAMPLES OF NEXTGEN TEMPLATES

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EXAMPLES OF NEXTGEN TEMPLATES

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WHAT IS THE STATUS OF PRAPARE?

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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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Dissemination

PRAPARE PILOT TESTING IMPLEMENTATION TEAMS AND ELECTRONIC HEALTH RECORDS

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IN DEVELOPMENT: IMPLEMENTATION AND ACTION TOOLKIT

Cate tego gori ries Exa xamples s of Po Potenti tial Resources rces to to Incl clude Step 1: Understand the Project

Project overview, project framework, defining risk, case studies, FAQs

Step 2: Engage Key Stakeholders

Messaging materials, change management guidance

Step 3: Strategize the Implementation Plan

Readiness assessment, PDSA materials, 5 Rights Framework, Implementation timeline, progress reports, legal documents

Step 4: Technical Implementation

PRAPARE paper assessment, data documentation, EHR templates, sample data dictionaries, data specifications, data warehouse and retrieval strategies, guidelines for using design and requirements documents

Step 5: Workflow Implementation

Workflow diagrams, data collection training curriculum, lessons learned and best practices

Step 6: Understand and Report Your Data

Reporting requirements, sample database, sample data outputs, sample data analyses and reports, cross-tabulating data, evaluation protocol, population- level planning, guidelines for data integration

Step 7: Act on Your Data

Strategy for detecting risk, report on best practices and processes for using SDH data, examples of SDH interventions, SDH response codes, linking to enabling services codes

Step 8: Use Your Data to Drive Payment and Policy Transformation

Strategy to engage payers, funding SDH efforts, data visualization templates

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PRAPARE IS A NATIONAL MOVEMENT!

• Health centers in 8

states are either already using PRAPARE or are planning to begin using PRAPARE in 2016

• Health centers, state

associations, regional networks, and other health care

• rganizations in 20+
• ther states interested

in using PRAPARE

Use and Interest in PRAPARE

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HOW CAN PRAPARE BE USED AT YOUR ORGANIZATION?

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• How will tool be administered to the patient to ensure that it

accurately identifies the SDH the patient may have?

Right Information

• Who will collect the data and who will address the social

determinants identified?

Right Person

• How will resource information be organized so that it is readily

available and standardized for all?

Right Intervention Format

• How is the appropriate care team member notified to address the

SDH identified?

Right Channel

• When in the patient visit does it make sense to administer the tool

and when is the best time to address identified SDH?

Right Time in Workflow

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IMPLEMENTING PRAPARE: USING THE FIVE RIGHTS FRAMEWORK

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SAMPLE WORKFLOWS

Health Center Who Where When How Rationale CHC #1 Non-clinical staff (enrollment assistance) In exam 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, and community health workers) In patient advocate’s

• ffice

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 Medical Assistants In exam room Before provider MAs administer PRAPARE while patient is roomed but before provider. Want to get patient in to exam room as quickly as possible. However, often don’t finish because provider comes in to exam room. CHC #5 Care Coordinators No wrong door approach No wrong door approach, but mostly as care coordinators complete chart review and HRA Allows staff to address similar issues in real time that may arise from both PRAPARE and HRA

WHAT HAVE WE LEARNED FROM PRAPARE?

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WHAT WE’VE LEARNED FROM PILOT TESTING

Easy to use: On average, takes ~9 minutes to complete form Emotional Toll on Staff Staff find value in the tool: Helps them better understand patients and build better relationships with patients Patients appreciate being asked and feel comfortable answering questions Identifies New Needs, Often Leading to New Community Partnerships Made minor revisions to tool based on pilot testing feedback

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COMMON CHALLENGES ENCOUNTERED WHEN USING PRAPARE AND SOLUTIONS

Challen enge: e: Staff and Patients Don’t Understand Why Doing PRAPARE Solut ution: Use short script to explain to staff & patients why health center is collecting this

• information. Message around better understand

patient and patient’s needs to provide better care Challen enge: e: Have too much going on now to add another project Solut ution: Don’t market PRAPARE as new big initiative but as project that aligns with other work already doing (care management, ACO, enabling services, etc) Challen enge: e: How do we implement this without increasing visit time? Solut ution: Find “Value-Added” time, whether in waiting room, during rooming process, or after clinic visit Challen enge: e: Fitting PRAPARE into Workflow Solut ution: Incorporate into other assessments to encourage completion (Health Risk Assessment, Depression Screening, Patient Activation Measure, etc) Challen enge: e: Inability to Address SDH Solut ution: Message “Have to start somewhere and do the best we can with what we have. Collecting information will help us figure out what services to provide.”

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PERCENT OF PATIENTS WITH NUMBER OF SDH “TALLIES”

0% 5% 10% 15% 20% 25% 30% 35% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Tally Score Alliance/Iowa Waianae New York Oregon Total

3 CHCs 1 CHC 2 CHCs 1 CHC 7 CHCs N = 2,694 patients for all teams

DATA RESULTS

 SDH risks vary by community  Most common risks:

• High stress
• Having less than a high school education
• Uninsured
• Unemployed
• Preference for language other than English

 But, patients are very socially integrated,

• Half of patients in our pilot test see people that they care about more

than 5+ times a week.

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MATERIAL SECURITY

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

Food Clothing Utilities Rent/mortgage payment Transportation Child care Medicine or medical care Health Insurance Phone

Alliance/Iowa Waianae New York Oregon All Teams N = 2,980 for all teams

CORRELATION BETWEEN SDH FACTORS AND HYPERTENSION: ALL TEAMS

0% 10% 20% 30% 40% 50% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Tally Score % of POF % of the tally score with Hypertension

r = 0.61

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USING DATA ON THE SOCIAL DETERMINANTS OF HEALTH

HOW PRAPARE DATA HAS BEEN USED TO IMPROVE CARE DELIVERY AND HEALTH OUTCOMES

Ensure prescriptions and treatment plan match patient’s socioeconomic situation Build 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 community based

• rganizations to offer bi-directional referrals and

discounts on services (ex: Iowa transportation) Create risk score to inform risk adjustment Inform both Medicaid and Medicare ACO discussions and care management policies Bet etter er Unde derstand d INDI DIVID IDUAL Patient’s Socioec economic Situa uation Bet etter er Unde derstand d Need eds of Pa Patien ent POPUL ULATION ION Drive e STATE E and NATIO IONAL Care e Transfo formation Refer patients to needed social services, whether in-house or through community partnership Improve Community Resource Guide to ensure accuracy and appropriateness Inform advocacy efforts related to local policies around SDH Streamline and expand care management plans to better allocate resources to areas most in need Inform payment reform and APM discussions with state agencies (e.g., Medicaid) on caring for complex patients

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Guide policies to incentivize integrated care with social services Guide work of local foundations to pay for non-clinical services and partnerships

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Few resources Many resources Health Center Resources Local Community Resources Substantial resources within the health center Limited resources in the local community Substantial resources within the health center Substantial resources in the local community Limited resources in the local community Limited resources within the community health center Substantial resources in the community Limited resources within the health center

ASSESS WHERE YOU ARE IN TERMS OF RESOURCES (PEOPLE, PROCESSES, TECHNOLOGY) NEED

• Standardized data on patient

risk

RESPONSE

• Standardized data on

interventions

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BOTH are necessar ary y to demon

• nstr

trat ate health h cente ter value ue

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AAPCHO DATA COLLECTION PROTOCOL: THE ENABLING SERVICES ACCOUNTABILITY PROJECT

CATEGO GORY CODE Minutes CASE MANAGEMENT ASSESSMENT CM001 CASE MANAGEMENT TREATEMENT AND FACILITATION CM002 CASE MANAGEMENT REFERRAL CM003 FINANCIAL COUNSELING/ELIGIBILITY ASSISTANCE FC001 HEALTH EDUCATION/SUPPORTIVE COUNSELING HE001 INTERPRETATION IN001 OUTREACH OR001 TRANSPORTATION TR001 OTHER OT001

Enabl bling ng Services Ac Account untab ability ty Pro roject (ESAP) AP) The ONLY standar ardi dize zed d data syste tem m to track and docume ument t non-clini nical al enabling g services that help patient nts access care.

CONCEPTUAL FRAMEWORK

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Approp

• priat

ate Care (For health condition in question,

for example, # of doctor visits, exams/tests levels…)

Health h Outcome

• mes

(For example, ideal

• utcomes, reduced

complications, ED visits, etc..)

Enabl bling ng Servi vice ces s & other non-cl clini nical cal inte terventi ntions

• ns

Social al Determi minant ants of Health (PRAPARE Domains:

Race/ethnicity, poverty employment, English proficiency, etc..)

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NEXT STEPS

NEXT STEPS

Complete Implementation & Action Toolkit Phase II Spread

2016

Including: * Free EHR Templates—by May * Training Materials—by this summer * Model Interventions to Address the SDH—by this summer Including: * Standardized data on Interventions

• National PRAPARE

Learning Network

• State Based Action groups

* Validation * Translation * Pediatric PRAPARE Tool

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PRAPARE resources will be posted at www.nachc.com/research PRAPARE Tool Implementation steps and timeline Data Documentation AAPCHO’s ESAP technical and other resources at http://enablingservices.aapcho.org. PRAPARE info and listserv signup: Michelle Jester, mjester@nachc.org AAPCHO ESAP technical assistance: Tuyen Tran, ttran@aapcho.org

RESOURCES AVAILABLE TO YOU

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Stay tuned for date and time!!

 Email Michelle and mjester@nachc.org if interested  Will cover the following:

• Steps to implement the NextGen template in another clinic’s EHR system
• The particulars of using the NextGen PRAPARE template
• A health center’s experience in redesigning or modifying workflow to collect and respond to the

data on social determinants

• How the NextGen PRAPARE template can expedite the reporting and aggregation of data and

be used for patient and population-level interventions

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PRAPARE NEXTGEN-SPECIFIC WEBINAR

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QUESTIONS AND DISCUSSION