SOCIAL DETERMINANTS OF HEALTHSocial determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide

SOCIAL DETERMINANTS OF HEALTH

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

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

Healthcare Spending as a Percentage of GDP, 2013

3Value Driven. Health Care. Solutions.

https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/

Select Population Health Outcomes and Risks Factors



Health and Social Care Spending as Percentage of GDP



Factors that Impact Health



6 Key Components of Social Determinants of Health


1.Neighborhood and Built Environment

2.Health and Health Care

3.Social and Community Context

4.Education

5.Economic Stability

6.Food


Components and Related Social Issues


Https://www.gnyha.org/tool/training-primary-care-residents-on-the-social-determinants-of-health/

How Social Needs Impact Health


Watch this brief video on how social needs can impact

health: https://www.youtube.com/watch?v=_11xLlwKgWc

https://www.youtube.com/watch?v=_11xLlwKgWc

Where to Begin:


1. Know Your Patient Population

2. Know Your Medical Neighborhood

3. Initiate Referrals to Needed Resources/Follow-Up

1. Know Your Patient Population


• 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

Public Data


Screening the Needs of Your Patients


• 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

Clinical Domains of an Assessment Tool May Include:


• Education

• Employment

• Housing

• Social Integration

• Stress

• Incarceration

• Transportation

• Refugee Status

• Country of Origin

• Safety

• Food

Assessment Tools


Examples of Screening Tools


Example


Example


Assessment Tool Resources


• 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

https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/

http://www.nachc.org/wp-content/uploads/2018/05/PRAPARE_One_Pager_Sept_2016.pdf

https://sirenetwork.ucsf.edu/tools-resources/mmi/ihelp-pediatric-social-history-tool

https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf

https://www.ers.usda.gov/media/8282/short2012.pdf

http://academicdepartments.musc.edu/ohp/SFSP/FINAL-Hunger-Vital-Sign-2-pager1.pdf

https://www.floatinghospital.org/The-Survey-of-Wellbeing-of-YoungChildren/Overview.aspx

https://www.baylorhealth.com/PhysiciansLocations/Dallas/SpecialtiesServices/EmergencyCare/Documents/BUMCD-262_2010_HITS survey.pdf

2. Know Your Medical Neighborhood


Community Based Organizations


Some Ideas Of CBO’s To Reach Out To:


• 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

Try AuntBertha.com


3. Initiate Referrals and Follow-Up


• 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

organization

• 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

Demonstrating the Impact of Social Needs on Health


#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.



#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.


MENTAL HEALTH

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

Mental Health

Why Do We Want to Focus on Implementing

Behavior Health Treatment in Our Practice?


• Provider/staff satisfaction for efforts

• Decrease in patient noncompliance

• Patient satisfaction improvement

• Impact on the Total Cost of Care

Costs to Mental Illness & Physical Relationships


• Human Cost

• Cost to Society

• Financial Cost to the Healthcare System

Mental Health Affects Clinical Conditions & Outcomes

Adults with medical

conditions also have mental

health conditions


29% 68%

Adults with a mental

health condition also

have medical

conditions

Mental Health Affects Chronic Conditions & Outcomes


Why Target Specific Conditions?


Where to Begin:


Practice Readiness

• Practice Readiness Assessment

• Practice Checklist

Start at the Beginning:


Coordinated

Care

Co-located

Care

Integrated Care


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


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


Integrated

Care

• Medical services and behavioral health

services located either in the same facility

or 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

Resources/Tools for Integrating Behavioral Health


Start with Coordinated Care


• Know your patient population (especially

high-risk population)

• Community Service Partners/Tools

• Payor Service Support/Tools

• Collaborative Opportunities

Community Resource Guide


Example of a Payer Tool



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

https://www.phdmc.org/epidemiology/special-reports/743-health-disparities-report-1/file

https://data.cms.gov/mapping-medicare-disparities

https://www.healthypeople.gov/2020/data-search/health-disparities-data

http://www.countyhealthrankings.org/

https://www.cdc.gov/nchs/pressroom/states/ohio/ohio.htm

http://web.mhanet.com/SQI/Immersion/Readiness/Readiness_Assessment_0517.pdf

http://www.mcadamhs.org/document center/strategicplan/ADAMHS Board for Montgomery County 030518.pdf


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/

http://sbhihelp.org/integrated-care-solutions/

http://www.mcadamhs.org/

https://www.integration.samhsa.gov/

https://www.integration.samhsa.gov/integrated-care-models/CIHS_Framework_Final_charts.pdf

http://www.mcohiosheriff.org/document_center/Community/CR_Guide 5-3-18.pdf

https://www.caresource.com/documents/oh-sp-0124_coordination-of-health-care-exchange-of-information-form/

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

Kelley [email protected]

Beth [email protected]

Shannon [email protected]

Ashley [email protected]