SOCIAL DETERMINANTS OF HEALTH Yes, We Have a Role in Our Patients - - PowerPoint PPT Presentation

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SOCIAL DETERMINANTS OF HEALTH Yes, We Have a Role in Our Patients - - PowerPoint PPT Presentation

Oct 27, 2023 169 likes •616 views

SOCIAL DETERMINANTS OF HEALTH Yes, We Have a Role in Our Patients 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,

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SOCIAL DETERMINANTS OF HEALTH

Yes, We Have a Role in Our Patient’s Social Determinants of Health

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Value Driven.Health Care. Solutions.

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.

Social Determinants of Health (SDOH)

2

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Healthcare Spending as a Percentage of GDP, 2013

3 Value Driven.Health Care. Solutions. https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/

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Select Population Health Outcomes and Risks Factors

4 Value Driven.Health Care. Solutions. https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/

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Health and Social Care Spending as Percentage of GDP

5 Value Driven.Health Care. Solutions. https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/

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Factors that Impact Health

6 Value Driven.Health Care. Solutions. https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/

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6 Key Components of Social Determinants of Health

7 Value Driven.Health Care. Solutions.

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/

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Components and Related Social Issues

8 Value Driven.Health Care. Solutions. Https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/

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How Social Needs Impact Health

9 Value Driven.Health Care. Solutions.

Watch this brief video on how social needs can impact health: https://www.youtube.com/watch?v=_11xLlwKgWc

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Where to Begin:

10 Value Driven.Health Care. Solutions.

  • 1. Know Your Patient Population
  • 2. Know Your Medical Neighborhood
  • 3. Initiate Referrals to Needed Resources/Follow-Up
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  • 1. Know Your Patient Population

11 Value Driven.Health Care. Solutions.

  • 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

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Public Data

12 Value Driven.Health Care. Solutions.

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Screening the Needs of Your Patients

13 Value Driven.Health Care. Solutions.

  • 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

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Clinical Domains of an Assessment Tool May Include:

14 Value Driven.Health Care. Solutions.

  • Education
  • Employment
  • Housing
  • Social Integration
  • Stress
  • Incarceration
  • Transportation
  • Refugee Status
  • Country of Origin
  • Safety
  • Food
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Assessment Tools

15 Value Driven.Health Care. Solutions.

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Examples of Screening Tools

16 Value Driven.Health Care. Solutions.

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Example

17 Value Driven.Health Care. Solutions.

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Example

18 Value Driven.Health Care. Solutions.

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Assessment Tool Resources

19 Value Driven.Health Care. Solutions.

  • 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

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  • 2. Know Your Medical Neighborhood

20 Value Driven.Health Care. Solutions.

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Community Based Organizations

21 Value Driven.Health Care. Solutions.

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Some Ideas Of CBO’s To Reach Out To:

22 Value Driven.Health Care. Solutions.

  • 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
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Try AuntBertha.com

23 Value Driven.Health Care. Solutions.

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  • 3. Initiate Referrals and Follow-Up

24 Value Driven.Health Care. Solutions.

  • 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
  • rganization
  • 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

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Demonstrating the Impact of Social Needs on Health

25 Value Driven.Health Care. Solutions.

#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/

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26 Value Driven.Health Care. Solutions.

#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/

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MENTAL HEALTH

Yes, We Have a Role and Responsibility in the Treatment of our Patients Mental Health

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Why Do We Want to Focus on Implementing Behavior Health Treatment in Our Practice?

28 Value Driven.Health Care. Solutions.

  • Provider/staff satisfaction for efforts
  • Decrease in patient noncompliance
  • Patient satisfaction improvement
  • Impact on the Total Cost of Care
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Costs to Mental Illness & Physical Relationships

29 Value Driven.Health Care. Solutions.

  • Human Cost
  • Cost to Society
  • Financial Cost to the Healthcare System
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Mental Health Affects Clinical Conditions & Outcomes

Adults with medical conditions also have mental health conditions

30 Value Driven.Health Care. Solutions.

29% 68%

Adults with a mental health condition also have medical conditions

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Mental Health Affects Chronic Conditions & Outcomes

31 Value Driven.Health Care. Solutions.

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Why Target Specific Conditions?

32 Value Driven.Health Care. Solutions.

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Where to Begin:

33 Value Driven.Health Care. Solutions.

Practice Readiness

  • Practice Readiness Assessment
  • Practice Checklist
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Start at the Beginning:

34 Value Driven.Health Care. Solutions.

Coordinated Care

Co-located Care Integrated Care

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35 Value Driven.Health Care. Solutions.

Coordinated Care

  • Routine screening for behavioral health

problems conducted in the primary care or specialty care practice

  • Referral relationship between primary care

and behavioral health

  • Routine exchange of information between both treatment

settings

  • Primary/specialty care delivers behavioral health

interventions using brief algorithms

  • Connections made between the patient and resources in

the community may be done by either behavioral health or primary/specialty care

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36 Value Driven.Health Care. Solutions.

Co-located Care

  • Medical services and behavioral health

services are located in the same facility

  • Referral process for medical cases to be

seen by behavior specialists

  • Enhanced informal communications between the

primary/specialty care and behavioral health due to proximity

  • Consultation between behavioral health and medical

providers to increase the skills of both groups

  • Increase in the level and quality of behavioral health

services offered

  • Significant reduction of “no-shows” for behavior health

treatment

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37 Value Driven.Health Care. Solutions.

Integrated Care

  • Medical services and behavioral health

services located either in the same facility

  • r in separate locations
  • On treatment plan with behavioral and

medical elements

  • Typically, a team working together to deliver care, using a

prearranged protocol

  • Teams composed of a physician and one or more of the

following: physician assistant, nurse practitioner, nurse case manager, family advocate, behavioral health specialist

  • Use of a database to track the care of patients who are

screened into behavioral health services

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Resources/Tools for Integrating Behavioral Health

38 Value Driven.Health Care. Solutions.

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Start with Coordinated Care

39 Value Driven.Health Care. Solutions.

  • Know your patient population (especially

high-risk population)

  • Community Service Partners/Tools
  • Payor Service Support/Tools
  • Collaborative Opportunities
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Community Resource Guide

40 Value Driven.Health Care. Solutions.

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Example of a Payer Tool

41 Value Driven.Health Care. Solutions.

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42 Value Driven.Health Care. Solutions.

Resources:

Public Health Dayton and Montgomery County https://www.phdmc.org/epidemiology/special-reports/743-health-disparities-report-1/file CDC https://data.cms.gov/mapping-medicare-disparities Healthy People 20/20 https://www.healthypeople.gov/2020/data-search/health-disparities-data County Health Ratings and Road Maps http://www.countyhealthrankings.org/ CDC Stats of State of Ohio https://www.cdc.gov/nchs/pressroom/states/ohio/ohio.htm Example of Readiness Assessment Checklist http://web.mhanet.com/SQI/Immersion/Readiness/Readiness_Assessment_0517.pdf ADAMHS Board of Montgomery County 2018-2020 Strategic Plan http://www.mcadamhs.org/document%20center/strategicplan/ADAMHS%20Board%20for%20Mont gomery%20County%20030518.pdf

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43 Value Driven.Health Care. Solutions.

Resources Continued:

Samaritan Behavioral Health http://sbhihelp.org/integrated-care-solutions/# Montgomery County, Ohio - Alcohol, Drug Addiction & Mental Health Services http://www.mcadamhs.org/ SAMSHA-HRSA https://www.integration.samhsa.gov/ Model for Integration Framework https://www.integration.samhsa.gov/integrated-care-models/CIHS_Framework_Final_charts.pdf Montgomery County- Drug Free Coalition Resource Guide http://www.mcohiosheriff.org/document_center/Community/CR_Guide%205-3-18.pdf Care Source Coordination of Care Exchange of Information https://www.caresource.com/documents/oh-sp-0124_coordination-of-health-care-exchange-of- information-form/

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ValueDriven.HealthCare.Solutions. Value Driven.Health Care. Solutions.

Kelley Montague

kmontague@medadvgrp.com

Beth Hickerson

bhickerson@medadvgrp.com

Shannon Kiffer

skiffer@medadvgrp.com

Ashley Tuley

atuley@medadvgrp.com