1. Focus on Quality Behavioral Health and Social Determinants of Health
April 10, 2019
Indiana Primary Health Care Association

2. Welcome!
Please keep phones muted while not speaking to eliminate background noise.
If you are using your computer for audio, click the microphone button next to your name to mute.
Do not place calls on hold, so we don’t hear hold music.
Use the chat box features if you have any questions that come up during the presentation.
Please complete the evaluation poll by the end of the meeting.
Note, this meeting will be recorded and shared with peers.

3. Agenda Welcome and identify objectives
Overview of PRAPARE and IPHCA’s involvement
Overview and updates from FSSA on the Office of Healthy Opportunities initiatives
Using Empathic Inquiry to engage patients and collect SDOH
Discuss promising practices in collecting SDOH at the CHC
Announcements and Events
Jasmine introduce

4. Introductions
If you only called in please state your name and health center
If there are multiple people in the room, enter their names and into the Chat Box.
Carla

5. Clinical Quality Metrics
Measures of Focus
Colorectal Cancer Screening
Cervical Cancer Screening
Hypertension Control
Childhood Immunization
Diabetes Control
Behavioral Health Screening
Clinical Quality Metrics
We have 6 measures of focus; this quarter we begin with a focus on Depression Screening and Behavioral Health

6. Focus on Systems
Connecting to PCMH and the process of engaging patients

7. The Speed of Trust
You can ignore the principles that govern trust—but they will not ignore you.
STEPHEN M. R. COVEY

8. SDOH and Patient Centered Medical Home
Capturing SDOH data can be used for many reasons including receiving both core and credits for the National Committee for Quality Assurance’s PCMH application.
Knowing and Managing Your Patients(KM) actually includes the words SDOH in the competency criteria.
KM 02 (Core) Comprehensive Health Assessment: Comprehensive health assessment includes 9 items, including Social Determinants of Health
KM 07 (2 Credits) Social Determinants of Health: Understands social determinants of health for patients, monitors at the population level and implements care interventions based on these data.
KM 21 (Core) Community Resource Needs: Uses information on the population served by the practice to prioritize needed community resources.

9. SDOH and PCMH (Cont.)
Care Management and Support (CM) includes SDOH data, but it is more subtle.
CM 03 (2 credits) Comprehensive Risk-Stratification Process: Applies a comprehensive risk-stratification process for the entire patient panel in order to identify and direct resources appropriately. (SDOH data does figure into the Azara DRVS risk-stratification algorithm.)
CM 04 (Core) Person-Centered Care Plans: Establishes a person-centered care plan for patients identified for care management. (The care plan may also address community and/or social services.)
CM 07 (1 credit) Patient Barriers to Goals: Identifies and discusses potential barriers to meeting goals in individual care plans. (Identifying SDOH barriers and then addressing them can help to empower patients to set and complete their goals.)
Contact Carla Chance, for questions and more info

10. Background
PRAPARE is a project that is supported through funding from the Kresge Foundation, Blue Shield of California Foundation, and Kaiser Permanente
Tool was developed in 2014 and tested with several PCAs, HCCNs, and health centers across the country
Jasmine

11. Why Collect data on Social Determinants of Health?
Clinical factors only account for 10-20% of health status of a population
This figure is provided by the Robert Wood Johnson Foundation’s County Health Rankings. This model is used to assess population health.
Only 10-20% of health is determined by healthcare, the rest is behavioral, environmental, and genetic factors
Addressing SDH is not one industry alone can solve, requires several partners (this is why we are here today)
Social and economic factors make up almost half of the factors that influence health
Figure from Robert Wood Johnson Foundation County Health Rankings

12. PRAPARE Domains Optional Granular
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?
Paper version of PRAPARE tool in folders

13. IPHCA’s Background with PRAPARE
IPHCA is one of eight organizations who participated in the PRAPARE Train the Trainer Academy
Arizona, Colorado, Maine, Massachusetts, Minnesota, North Carolina, Washington State
Partnered with three health centers during Train the Trainer pilot
Developed training model and witnessed implementation improvements
PRAPARE Peer Learning Collaborative
Four health centers with 3 different EHRs

14. Indiana SDOH Measures of Interest
Measures Collected from FSSA assistance applications (Medicaid, SNAP, TANF)
Food
Utilities
Housing Security
Childcare
Healthcare access
Transportation
Health literacy
Safety
Employment
Physical Activity

15. Measures of Interest: PRAPARE
Indiana FSSA Voluntary Assessment
 SDoH Area
IPHCA PRAPARE Tool
In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?
Food
In the past year, have you or any family members you live with been unable to get food when it was really needed?
In the last 12 months, has your utilities company shut off your service for not paying your bills?
Utilities
In the past year, have you or any family members you live with been unable to get utilities when it was really needed?
Are you worried that in the next 2 months, you may not have stable housing?
Housing Security
Are you worried about losing your housing?
Do problems getting child care make it difficult for you to work or study?
Child Care
In the past year, have you or any family members you live with been unable to get child care when it was really needed?
In the last 12 months, have you needed to see a doctor but could not because of cost?
Health Care
In the past year, have you or any family members you live with been unable to get medicine or any health care when it was really needed?
In the last 12 months, have you ever had to go without health care because you didn't have a way to get there?
Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
Are you afraid you might be hurt in your apartment building or house?
Safety of Home/Communit y
Do you feel physically and emotionally safe where you currently live?
During the last 4 weeks, have you been actively looking for work?
Employment
What is your current work situation?

16. Today’s Objectives After this session I will be able to:
Identify the SDoH initiatives at the state level and how they connect with PRAPARE and current initiatives.
Discuss the background of FSSA’s Office of Healthy Opportunities.
Describe three action-oriented principles for developing a patient-centered approach to conversations about social needs.
Describe how Empathic Inquiry is consistent with patient engagement best practices.

17. Today’s Guest Presenters
Daniel Rusyniak, MD
Chief Medical Officer, FSSA
Family and Social Services Administration
Ariel Singer, MPH
Transformation Director
Oregon Primary Care Association
Ru-SIN-E- ACK

18. Peer Sharing on Collecting Social Determinants of Health
What approaches are you using to engaging patients in collecting SDOH information?
How do you plan to use this data?

19. Announcements & Events
PCMH Training Opportunity
Social Determinants of Health Webinar Series: Infant Mortality Prevention with Dr. Nancy Swigonski from IU School of Medicine
April 16, 2019 at 11 am EDT
IPHCA Annual Conference
Visit indianapca.org “Events” for more IPHCA events