Social Determinants of Health (SDOH) and Integrated Care

Natalie Slaughter, FacilitatorCourtney Wiggins, Co Facilitator

Session 3: Assessing Community SDOH: Data Collection and Technology Tuesday, May 11, 2021

Session Two

Welcome Back!

Housekeeping Items

Polling Questions –mark your answers to each question.

Click “submit” to complete the poll.

Session Guest Speaker and Facilitators

Guest Speaker – Bonni Brownlee MHA CPHQ PCMH-CCE, Senior Consultant, Healthcare Solutions

Division, Advocates for Human Potential .

Co-Facilitator – Courtney WigginsPublic Health Analyst

The Bizzell Group

4

Facilitator – Natalie Slaughter, M.S.P.P.M.Technical Expert LeadJBS International, Inc.

Agenda

• Participant check-in

• Session 3 objectives

• Subject Matter Expert (SME) Presentation and Discussion –“Assessing Community SDOH: Data Collection and Technology.” Guest speaker: Bonni R. Brownlee, MHA, CPHQ, PCMH-CCE

• Discussion/Q&A

• Between-session Activity

• Wrap Up/Next StepsSource: iStock

5

Participant Check-in

Image source: iStock by Getty Images

Have you made any progress in identifying your goals and building your team in development of your action plan?

Today’s Learning Objectives

At the end of this session, participants will be able to• Describe health center strategies for using SDOH data. • Explore the use of SDOH assessment tools, data resources, and mapping

tools. • Describe data-sharing protocols among partners. • Discuss SDOH Considerations for COVID prevention and vaccination

within the community.

Source: iStock

Your Action Plan – to be presented June 1st!

8

Today’s Discussion Question

Later in the session, we will ask:

What action item can you put into your action plan related to identifying reliable data sources and assessment tools for SDOH?

9

Source: ThinkStock

Assessing Community SDOHData Collection and Technology

Social Determinants of Health

Source: Alliance for the Determinants of Health, Utah

National Investment in SDOH• Medicaid waivers

• Medicare CMMI – Accountable Health Communities Model; Integrated Care for Kids Model

• Large health systems in 30 states, primarily not-for-profits, the majority participating in ACO.− Motivated by mission and values− Alignment with ACO business case

• Investmentso 1.6 B Housingo 1.0 B Employmento 476 M Educationo 294 M Food securityo 253 M Social and communityo 32 M Transportation

Source: Quantifying Health Systems’ Investment in SDOH, by Sector, 2017-2019. Health Affairs, February 2020

Health centers use SDOH data to: HEALTH CENTER ADMINISTRATION• Support grant applications• Conduct Community Health Needs Assessments• Guide service planning and infrastructure• Complete UDS reporting• Inform emergency preparedness plans

CLINICAL CARE• Care Coordination, Care Management, Care Transitions – inform care planning• Help with risk stratification• Reduce health disparities• Develop community partners to meet patients’ needs

Poll 1

• Support grant applications• Conduct Community Health Needs Assessments• Guide service planning and infrastructure• Complete UDS reporting• Inform emergency preparedness plans• Care Coordination, Care Management, Care Transitions – inform care planning• Help with risk stratification• Reduce health disparities• Develop community partners to meet patients’ needs

How does your health center use SDOH data? Select all that apply.

PRAPARE – a SDOH Assessment Tool

• Race, ethnicity*• Migrant/Seasonal farm worker*• Veteran status*• Language*• Housing status*• Housing stability*• Address/Neighborhood*• Education• Employment*

• Insurance*• Income*• Material Security• Transportation• Social Integration and Support• Stress• Incarceration History• Refugee Status• Domestic Violence• Safety

© Wipfli LLP 15

Prepare to Respond to and Assess Patients Assets, Risks and Experiences

*UDS Reports

Poll 2

Are you currently collecting SDOH data, beyond those items required for UDS?

A. YesB. No

Poll 3

Are you using the PRAPARE Tool to capture SDOH data?

A. YesB. No

Poll 4

Are you conducting a verbal interview and manual data entry?

A. Yes B. No

Poll 5

Are PRAPARE data fields available in your EHR system?

A. Yes B. No

Data Resources and Mapping Tools

CAREShqCenter for Applied Research and Engagement Systems, Univ of Missouri

• Community Commonso Vulnerable Populations

Footprint• Community Health Needs

Assessment Toolo SparkMap

https://careshq.org/map-room/

https://www.communitycommons.org/collections/Maps-and-Data

Centers for Disease Control and Prevention

• Social Vulnerability Index

http://svi.cdc.gov

Policy Map www.policymap.com/industries/communityhealth

Data options for Vulnerable Popns Footprint, under category Health

•Children and Families•Clinical Care•Deaths of Despair•Food•Health Behaviors•Health Facilities / Professionals•Health Insurance•Health Outcomes•Health Policies•Health Rankings•Health Spending

Community Health Needs Assessments (CHNA)

Assessment1. Location 2. Data Indicators 3. Reports

Data Indicators - Select data indicators to include in your report Demographics Income and Economics Education Housing and Families Other Social & Economic Factors Physical Environment Clinical Care and Prevention Health Behaviors Outcomes Healthcare Workforce Special Topics - COVID-19

https://careshq.org/assessments/

SDOH informs risk; Risk stratification informs care planning

22

5%

30%

10%15%

40%

Determinants of Health

EnvironmentGeneticsMedical CareSocial FactorsPatient Choices

Source: healthcatalyst.com 2018

What factors can risk stratification influence?

SDOH Considerations for COVID Prevention and Vaccination within the community

• Social Vulnerability refers to the resilience of communities (the ability to survive and thrive) when confronted by external stresses on human health, stresses such as natural or human-caused disasters, or disease outbreaks. Reducing social vulnerability can decrease both human suffering and economic loss.

• Socially Vulnerable Populations include those who have special needs, such as, but not limited to, people without vehicles, people with disabilities, older adults, and people with limited English proficiency. With the COVID pandemic, distance to hospital, chronic disease burden, housing

status are major vulnerability factors.

Source: Centers for Disease Control and Prevention/ Agency for Toxic Substances and Disease Registry/ Geospatial Research, Analysis, and Services Program. CDC Social Vulnerability Index

Social Vulnerability Index

SDOH data can predict pandemic outbreaks

SJC COVID Incidence MapSJC SVI Housing/Transportation Map

SOURCE: Tracking Vulnerable Population by Region, COVID 19 Healthcare Coalitionhttps://c19hcc.org/resource/vulnerable-population

Median Vulnerability IndexMedian Medical Risk FactorMedian Social Risk FactorMedian Health Care Resource Risk FactorMedian CDC Social VulnerabilityMedian Unmet Need ScoreMedian Below 200% FPL

Median age 65 and olderMedian American IndianMedian Below 200% FPLMedian COPDMedian CancerMedian DiabetesMedian Distance to Hospital

Open Discussion

Image by Gerd Altmann from Pixabay

Discussion Question

Source: ThinkStock

28

What action item can you put into your action plan that is related to identifying reliable data sources and assessment tools for SDOH?

Next Steps

• Choose an action item related to today’s presentation that will help your health center take a step in identifying and screening for SDOH in the communities in which you serve.

• Before next week’s session, using the action plan worksheet, work with your team to build out that action item.

• Review the Patients’ Assets Risks, and Experiences (PRAPARE) assessment tool and be prepared to discuss during our next session.

• Remember Office Hours on Tuesdays and Wednesdays —see you there!

29

Source: iStock by Getty Images

Reflecting on Today: Plus, Delta

Considering today’s topic:

• + What worked for you today?

• What would you change?

• Is there other technical assistance on this topic that can we provide?

• Upcoming Sessions: What other information do you hope to hear about in upcoming sessions?

Office Hours

• Tuesdays (following today’s session) 4:00–5:00 p.m. ET

• Wednesdays 2:00–3:00 p.m. ET

• Designed to discuss progress and/or challenges related to• The session topic,• Your team’s CoP goal, and• Support in between session activity.

31

TA Offerings for Health Centers: BPHC-BH TA Portal

https://bphc-ta.jbsinternational.com/

• Request TA• Access Learning Management System

(LMS) modules• Learn more about BH TA options

• One-on-one Coaching• E-learning Webinars• Strategies for Community Outreach• Virtual Site Visits to Improve

Outcomes• Join a Community of Practice (CoP)

Upcoming TA Opportunities!

Webinars Strategies for Addressing Health Disparities in Medication Assisted Treatment for Opioid

Use DisordersWednesday, June 2, 3:00 – 4:00 p.m. ETRegistration Link: https://zoom.us/webinar/register/WN_hUz8J4lvQ0eidc8x6XCkFQ

Reducing Health Disparities by Addressing Integrated Behavioral Health in a Maternal Child Health Care Setting

Thursday, July 29, 3:00 – 4:00 PM ET • Registration Link: https://zoom.us/webinar/register/WN_smCvIfV5RP2qz5awjlYZrA

Registration links for webinars can also be found on the BPHC-BH TA Portal.

You can receive 1 hour of Continuing Education credit for your participation.

33

Upcoming TA Opportunities! (cont’d)

Communities of Practice (CoPs) Integrated Behavioral Health and Value-Based

Reimbursement: Two Sides of the Sustainability Coin

Cohort 2: Thursdays, 6/10/21 – 7/15/21, 2:30–4:00 p.m.https://zoom.us/meeting/register/tJUuduqhpjIuHtwabD2xSdkmuHLR5Qju0XeD

34

~HRSA Health Center Program

Continuing Education

• We will be offering 1.5 CE credit per session attended for a maximum of 9 CEs for participation in all 6 CoP sessions.

• You must complete the Health Center Satisfaction Assessment after each session for which you plan on receiving CEs.

• CE credits will be distributed for all sessions at the conclusion of the CoP.

This ,ooms,e has been apprnved by JBS Intern at ional, Inc. as a NAADAC Approved Educat ion Provider, for educat ional ,credits. NAADAC Provider #86&3 2., JBS intern ati onal, Inc. is responsible for .all .aspects of t hei r programming.

JBS Intern atio nal, Inc. has been approved by NB.CC as an Approved ,continui g Ed ucation Provider, ACEP No. 6442.. Program s that do not qualify for NB.OC ,credi are d early identified. JBS Intern at ional, Inc. is s,olely respon sible for .all aspects of the programs.

CoP Satisfaction Assessment

• Please complete a satisfaction assessment of today’s session.

• If you plan to obtain CEUs for your time in this CoP, the Satisfaction Assessment is required.

• There are two ways navigate to the assessment:

1. Follow the link provided in the chat here.

2. You will be emailed a link from us via Alchemer, our survey platform.

Thank You!Presenter Contact Information:

Bonni R. Brownlee, MHA, CPHQ, PCMH-CCE, bbrownlee@ahpnet.comNatalie M. Slaughter MSPPM, nslaughter@jbsinternational.com

BREAK

Tuesday Office Hours 4:00–5:00 p.m. ET