James M. Anderson Center for Health Systems Excellence James M. Anderson Center for Health Systems Excellence Recommended Social and Behavioral Domains.

James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence

Recommended Social and Behavioral Domains and Measures for Electronic

Health Records

Robert S. Kahn, MD MPH

Cincinnati Children’s Hospital Medical Center

November 25, 2013

Achieving Potential

Esteem and Respect

Belonging

Safety and Security

Physiological

What We See in Clinic Hierarchy of Needs How We Respond

• Unemployment• Lack of high school degree• Ex-offender reentry issues

• Food insecurity• Denial/delay of public benefits• Utility shut offs• Poor housing conditions

• Inadequate education services• Domestic violence• Adult mental health issues

• Distressed/depressed parents• Lack of parenting role models

Henize, Kahn

Benefits

Housing

ParentalDepression

Domestic Violence

Food Insecurity

Social Risk Screening

School Related Screening

EHR Referrals: Legal Aid Society

Current Month Referrals Oct. 2013

Last Month ReferralsSep. 2013

Last 12 Month Referrals

Nov. 2012 - Oct. 2013

Last 12 Month

Monthly Average

Last 12 Month Monthly Average

Rate of Referrals per 1000 Well Child Visits

SITESAll 83 71 774 65 24

PPC 59 49 577 48 31Fairfield 12 17 124 10 17Hopple 12 5 73 6 11

PROVIDERSAll 83 71 774 65

Resident 32 19 279 23Attending/Other 47 51 465 39

Social Worker (Direct) 4 1 30 3

Social Worker (Facilitated)* 14 19 155 13

Current Month Opened Cases

Oct. 2013

Last Month Opened Cases

Sep. 2013

Last 12 Month Opened Cases

Nov. 2012 - Oct. 2013

Last 12 Month

Monthly Average

% of Last 12 Month Monthly Average

CASE TYPEAll 56 40 608 51

Health/Income 17 17 188 16 31%Housing 24 16 249 21 41%Family 7 2 68 6 11%

Education 8 5 85 7 14%Misc. Legal 0 0 18 2 3%

*Referral preceded within 72 hours by

physician visit

Tracking of EHR-based Legal Aid Referrals

Referrals to the Health Department

Change in physician behavior

Percent with household food insecurity identified

Change in physician behavior

0

5

10

15

20

25

30

EHR driving social determinants focusAsthma admission rate per 1000 children, by neighborhood

EHR data driving focus on broader social risks

2-3 risks

Days from the index admission

1 risk

2-3 risks

0 risks

Pro

port

ion

wit

hout

reu

tili

zati

on

d

Days from the index admission

*Risks: census tract extreme poverty, adult educational attainment, median home value

Risks* Rate of asthma reutilization at 1y

0 30%

1 38%

2-3 45%

Broader social risks informing clinical care: Census tract-level risks and asthma reutilization risk

Additional considerations

• Intergenerational information from parents’ EHR– Prenatal/obstetric history– Family history (e.g., smoking, obesity)

• Information from school’s database– Grades, missed school days, suspensions

EHR-related studies in social determinants

• Beck AF, Sauers H, Kahn RS, Yau C, Weiser J, Simmons JM. Improved documentation and care planning with an asthma-specific history and physical. Hospital Pediatrics 2012; 2:194-201.

• Beck AF, Simmons JM, Huang B, Kahn RS. Geomedicine: area-based socioeconomic measures for assessing risk of hospital reutilization among children admitted for asthma. American journal of public health 2012;102:2308-2314.

• Burkhardt MC, Beck AF, Conway PH, Kahn RS, Klein MD. Enhancing accurate identification of food insecurity using quality-improvement techniques. Pediatrics. Feb 2012;129:e504-510.

• Beck AF, Klein MD, Schaffzin J, Tallent V, Gillam M, Kahn RS. Identifying and treating a cluster of substandard housing using a medical-legal partnership. Pediatrics. 2012; 130:831-8 .

• Beck AF, Simmons JM, Sauers HS, Sharkey K, Alam M, Jones C, Kahn RS. Connecting at-risk inpatient asthmatics to a community-based program to reduce home environmental risks: care system redesign using quality improvement methods. Hospital Pediatrics 2013;3:326-334.

• Klein MK, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children – outcomes from a successful partnership between professions. Journal of Health Care for the Poor and Underserved. 2013; 24:1063-1073.