1. Screening for Social Determinants of Health Ellie Zuehlke, Director Community Benefit & Engagement Nicole Truniger, Manager Clinical Services Hot Topics in Pediatrics May 12, 2017

2. Why Address Social Determinants of Health?
Health outcomes largely determined by factors outside clinical care.
Health-related social needs, health behaviors and the physical environment significantly drive health care utilization and costs
Emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and impact costs
A combined ‘medical model’ and ‘population level’ strategy is needed because “a large number of people with small risk may give rise to more cases of disease than the small number who are at high risk“ (Rose, 1985).

3. Current Efforts at Allina Health to address social determinants
CMS Accountable Health Communities Model
NowPow community collaboration with HCMC, Children’s, HealthPartners, and dozens of community organizations
Clinic Community Connection Pilot

4. What is the CMS Accountable Health Communities Model?
The Accountable Health Communities Model is a 5-year model that tests whether systematically identifying and addressing the health-related social needs of community-dwelling Medicare and Medicaid beneficiaries impacts health care quality, utilization and costs.
Three different tracks/models will be tested- Allina will implement the Track 2- Assistance Pathway
Total of 44 grantees Nationwide, Allina Healthonly Minnesota grantee

5. CMS Accountable Health Communities Track 2- Assistance Pathway

6. Accountable Health Communities Screening for Health-Related Social Needs
CMS Screening Tool
Core Needs (required by CMS):
Housing Instability
Utility Needs (eg. difficulty paying utility bills)
Food insecurity
Interpersonal Violence
Transportation
Supplemental Needs (identified in Allina’s CHNA):
Family and social supports related to mental health and wellness (eg. social isolation and caregiver support)
Health behaviors related to obesity (eg. community-based resources for physical activity and healthy eating, wellness classes, etc)

7. What is NowPow Software?
Based on technology developed by Dr. Stacy Lindau at the University of Chicago to connect patients to community resources

8. What does NowPow do? AWARENESS ENGAGEMENT ACTIVATION
Health Care Providers
Community
Organizations
Build MeaningfulRelationships
Connect to Engaged Resources
Track Activation and Outcomes
AWARENESS
ENGAGEMENT
ACTIVATION
People
Manage Supply and Demand
Navigate to
Resources

9. 3P Planning Event to Develop Pilot
28 participants over four days in November 2016
Clinical Assistant
Community Engagement
Patient
Clinic manager
Community Organizations
Community Paramedic
Family Practice Provider
Pediatric Provider
Primary Care RN role
AHG Care Coordination
Business Supervisor
Northwest Alliance

10. Pilot Project Scope
Develop and test a process in Pediatrics and Family Practice at the Coon Rapids Clinic to screen Medicaid patients for:
food insecurity
housing
utility needs
transportation
Connect patients to appropriate community resources to address identified needs

11. Clinic Community Pilot Overview
Patient completes a brief screening form in exam room
Clinical Assistant uses NowPow to automatically generate tailored community referral summary
If patient would like additional assistance, warm hand-off to Referral Specialist with additional training and full NowPow access
Community partners help patients to address identified needs
Social worker available for high need patients.

12. What do we hope to learn from the pilot?
How much and what types of health-related social needs do we find?
How feasible is it to assess health-related social needs and refer to community resources in a clinical setting (process)?
How effective is the pilot in referring to community resources? (technology, communication, trust)
How do lessons learned affect the potential to adapt it to other sites?

13. Clinic Staff Experiences Pre-Pilot
Staff in the two departments at Coon Rapids were asked their experience and perceptions prior to the pilot. Twenty-nine people gave input.
All providers who responded (n=9) said they had spoken with a patient about his/her social needs at least once in the last month.
Providers were much more likely than clinical assistants to have discussed social needs with patients previously.
In order to understand the baseline experience of staff at the clinic, we asked for their input before starting the pilot. Given that the pilot is initially limited in scope, most of the 29 respondents to the survey are NOT currently in the pilot.
Although there is no formal tracking of health-related social needs, staff indicate that these needs do surface during patient visits. Providers were more likely to indicate that they had discussed needs directly with a patient and the frequency ranged from at least one time per month to weekly or more.

14. Clinic Staff Perceptions Pre-Pilot
Almost three quarters of clinic staff agree that addressing social needs is as important as addressing medical conditions and that Allina Health should invest resources to help address patients’ needs. The same proportion of staff also believe that, with support, they can help their patients meet these needs by connecting them with resources.
Fewer staff, but still a majority, thought that their patients unmet social needs prevent them from providing quality care.

15. Pilot Timeline and Progress
Pilot began in late January with two provider teams in Pediatrics and one team in Family Practice
Results to-date:
Pediatrics: 
136 screenings have been completed (10 declined)
37% of patients screened had at least one need identified
Housing most common followed by utilities
Family Practice:
60 screenings have been completed (2 declined)
43% of patients screened had at least one need identified
Utilities most common followed by housing
- Began with curated list of resources in CR area. End of march we received training on Now Pow and added the resource of MCH for high need patients.

16. Learnings to date
Most patients are willing to answer the questions, anecdotally many have been very appreciative- several ‘success’ stories!
Providers and Clinical Assistants do not feel process is burdensome
Fewer patients than expected wanting to meet with a referral specialist for more assistance
Several patients identified more than one need and a few identified needs that are not part of screening
Some patients have significant needs (such as current homelessness) and need additional assistance. Our most recent workflow includes connecting these patients with the Coon Rapids Mental Health Consultant, Renee
Warm handoff/same day visit important
1. No patients irritated since we have the option to decline screening. Many patients stating appreciation for asking these questions.
2. Providers can do little work or be very involved. A bit more work for staff, however with our team care model we are able to maintain patient flow, no delay in rooming patients.
3. We utilize internal resource, of referral specialists, at times this can be overwhelming as it is added work to the role of the RS, however, with volumes fluctuating so much it is hard to support a full time staff during pilot period.
Pediatric patient identified transportation need. Her response to offer of help: “Oh, I didn’t think there was anything you could do to help me!” 
The referral specialist called a transportation resource and guided the patient through next steps for a car repair.
Patient screened as having all four needs.  Patient was previously unable to receive help.  
The referral specialist used resources on our list to provide alternate options to meet the patient’s need.
Family practice patient identified no needs on the form but wanted to talk to referral specialist.
Needed prescription assistance
Was walked to Patient service representative (PSR) who helped the patient get set-up with the program.
The screening form helped start a conversation that likely would not occur without prompting.
This example highlights that in addition to providing support for patients with one of the four needs selected for this Pilot, other needs have been identified and addressed as a result of opening the conversation about how the clinic can support them with health-related needs.
Another patient listed clothing as an additional need and learned through the information that we provided her that other resources, such as food shelves, often provide clothing support.
Several success stories with use of social worker (MHC), patient called back after her appointment to say how much she enjoyed meeting with her and receiving additional help.
Noting it is important to have patient go to social worker same day, via warm handoff, as often do not return for their scheduled time with her.