Clinic strategies around social needs and chronic disease prevention

It is broadly recognized that the social determinants of health and health equity significantly impact length and quality of life and systematically contribute to inequities across and within populations. These inequities include social needs such as food insecurity, housing insecurity, and limited transportation. There are increasing interests and efforts to understand and incorporate patient’s social needs in a clinical setting as part of whole patient care.

ORPRN partnered with the Oregon Health Authority Public Health Division, Health Promotion and Chronic Disease Prevention Section to provide education and technical assistance to clinics in Oregon through the Social Determinants of Health and Health Equity Population Approaches to Chronic Disease Prevention (SDOH-HE) program. The purpose of this program was to support clinics in increasing social needs screening rates and using social needs data to inform clinical interventions to prevent and manage diabetes and cardiovascular disease and improve health equity. The program involved learning sessions and individualized technical assistance where clinics were supported in identifying a patient population with greater need followed by developing and implementing an intervention for that population. Clinics participated in the SDOH-HE program from July 2021 to June 2022.  

Every clinic that participated in the program had a unique approach. These are some strategies clinics used to improve social needs screening and data use. 

• Identify a patient population and intervention that are manageable for the people involved.
• Identify screening questions that are applicable to the patient population and for which resources are available in the clinic or community.  
• Include a champion or people that are interested in the work.
• Create buy-in from the clinic and people actively doing the work.
• Use a team approach and involve the entire care team including registration staff, medical assistants, providers, community health workers, etc.
• Build on the processes and resources that are already in place. Do not reinvent the wheel.
• Include opportunities for small successes. Celebrate small successes and recognize staff that contributed.
• Connect quality improvement work with other initiatives and goals that are already established.
• Make it fun!

ORPRN is continuing to work with clinics on quality improvement around patient’s social needs and chronic disease prevention and management through July 2023. If you are interested in more information or participating in this program, please contact Sara Wild (wilsa@ohsu.edu), MPH, Research Project Manager.

Cascades East Family Medicine Center

Cascades East Family Medicine Center is located in Klamath Falls, Oregon. Cascades East Family Medicine Center has been screening all patients for food insecurity annually for two years. The SDOH-HE program was an opportunity to explore additional social needs screening questions that are applicable to the patient community and to expand social needs screening and navigation to resources.

Patient population identification:

Cascades East Family Medicine Center identified obstetric patients as a priority population through weekly care management team meetings, where discussion increasingly focused on obstetric patients struggling with food or housing insecurity and communication needs (not having a phone). Obstetric patients were also seen as a manageable sized group to pilot social needs workflows in connection with chronic disease prevention and management compared to including all patients with diabetes. About 10% of obstetric patients at Cascades East Family Medicine Center have gestational diabetes.

Intervention development and implementation:

Cascades East Family Medicine Center built from processes that were already in place to develop additional social needs screening and patient navigation for obstetric patients. They created a paper form for the new social needs screener, added it to the paperwork for new obstetric patients, and registration staff distributed the screener to new patients as they were identified. Medical assistants entered the screener responses into the electronic health record and pended a referral to outpatient care management when a patient screened positive for a social need. Involving the medical assistants in the referral process was helpful as it decreased the burden on the provider. Cascades East Family Medicine Center worked with their information technology department to add phone status to the care manager navigator as a flowsheet row.

Since the intervention was implemented, 28 new obstetric patients have been identified and 27 of them have been screened with the new social needs screener. 4 of these patients screened positive for food insecurity, 2 for housing insecurity, and none had a communication/phone need. Patients that screened positive were referred to the outpatient care management group and from there, 3 patients were referred to food resources.

Continuation:

Cascades East Family Medicine Center is working on a workflow for tracking the referral process and are exploring a closed loop referral with outpatient care management or follow-up with the patient. They are planning to scale up the intervention in the future and are communicating with outpatient care management about capacity for patient referrals as well as including more questions on the social needs screener and making sure they can provide resources for the topics included on the screener. Once scaled up, the screener will be implemented annually.

Useful Strategies:

• Identifying a manageable sized group of patients to pilot the process.
• Including registration and MA program champions.
• Whole team approach.
• Built on the processes and resources that were already in place.

Winding Waters Clinic

Winding Waters Clinic is located in Enterprise, Oregon. Winding Waters Clinic has been using the PRAPARE tool from the National Association of Community Health Centers for the past 4 years. A whole team approach, including community health worker and behavioral health teams, has been key to implementing the full screener and connecting patients with resources.

Patient Population Identification:

At the beginning of the SDOH-HE program, Winding Waters Clinic looked at their social needs screening rates for all patients and across patient subpopulations. They found that Medicare patients, which are about 30% of their patient population and are a population with high chronic disease rates, had low social needs screening rates. Winding Waters Clinic used the SDOH-HE program as an opportunity to train and coach staff on their social needs screener and workflow.

Intervention development and implementation:

Winding Waters Clinic reviewed the social needs screener and workflow with medical assistants and provided one on one coaching for newer staff as well as staff that had questions. An identified burden to screening patients for social needs was medical assistants feeling the need to carry the burden of identifying a solution when a patient screened positive. The training emphasized that the social needs screening, referral, and navigation to resources is a team process and no single role carries the entire burden: medical assistants scrub charts and inform the appointment desk staff if a patient has not been screened in the last 12 months; appointment desk staff give patients the screener in paper form; medical assistants enter the patient’s responses into the electronic health record; if a patient screens positive, the medical assistant makes the provider aware and the provider connects the patient with the community health worker team.

The clinic implemented a challenge where they asked each medical assistant to screen five Medicare patients for social needs over a month timeframe. The challenge was a fun and engaging way to motivate medical assistants to practice what they learned in the social needs workflow refresher and improve comfort level for newer staff that did not have experience asking social needs questions. Medical assistants were engaged in the challenge and completed the challenge well before the end of the month. Screening rates increased dramatically during the challenge and remained high after the challenge ended. The medical assistant that won the challenge was recognized at the following all staff meeting.

Continuation:

As screening rates improve for the Medicare population, Winding Waters is looking at the data and identifying trends in patient’s social needs. The clinic is working with their community health worker team to further engage this population and will continue to administer the social needs screener to all patients on at least an annual basis.

Useful Strategies:

• Make it fun!
• Recognize people that are doing a good job.
• Include opportunities for small successes in QI work; show and celebrate successes.
• Whole team approach.

Legacy Emanuel and Legacy Good Samaritan

Legacy Emanuel and Legacy Good Samaritan are located in Portland, Oregon and are part of Legacy Health. Legacy Health has identified food insecurity as a prevalent and growing need and has done extensive work to gather and implement resources to make an impact in this area. Both Legacy Emanuel and Legacy Good Samaritan have been screening patients for food insecurity as of February 15, 2022. The SDOH-HE program was an opportunity to involve residents in quality improvement and contribute to the larger food insecurity work happening across Legacy Health.

Patient Population Identification:

Residents at both clinics identified patients with either diabetes or heart failure who screened positive for food insecurity as their population of focus.

Intervention development and implementation:

Residents were interested in developing an intervention to raise awareness about food resources among patients that screen positive for food insecurity. They created a dot phrase to include in after visit summary paperwork, which includes information about Legacy Health food resources as well as external food resources. The dot phrase was a manageable task for residents to develop, implement, and evaluate while contributing to the larger food insecurity work at Legacy Health. Residents created a workflow and are implementing the dot phrase for all patients that screen positive for food insecurity.

Continuation:

Residents plan to evaluate implementation and satisfaction of the dot phrase among patients with either diabetes or heart failure who screen positive for food insecurity. They plan to calculate the percent of this population that have had the dot phrase included in their after visit summary paperwork. To evaluate satisfaction, residents plan to conduct a phone survey with a subset of this population to understand whether patients accessed food resources and to collect feedback on how residents can improve food insecurity support for these patients.

Useful strategies:

• Pick a manageable intervention and goal for the people involved.
• Buy-in from clinic and people actively doing the work.
• Screen for a social need(s) the clinic can do something about.
• Connect quality improvement work with other initiatives and goals that are already established.