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This project was made

possible with funding from:

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COLLECTING SOCIAL DETERMINANTS

OF HEALTH DATA USING PRAPARE

TO REDUCE DISPARITIES, IMPROVE

OUTCOMES, AND TRANSFORM CARE

WEBINAR AGENDA

Topic Facilitators Minutes

Importance of Collecting Data on the

SDH

Michelle Proser, NACHC 15 mins

How We Created PRAPARE Michelle Jester, NACHC 10 mins

Status of PRAPARE and How You Can

Use PRAPARE at Your Health Center

Alicia Atalla-Mei, OPCA 10 mins

What We’ve Learned Rosy Chang Weir, AAPCHO 15 mins

Using Data on the SDH Michelle Jester, NACHC and

Tuyen Tran, AAPCHO

15 mins

Next Steps and Q&A Michelle Proser, NACHC 25 mins

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WHY IS IT IMPORTANT TO

COLLECT STANDARDIZED DATA

ON THE SOCIAL DETERMINANTS

OF HEALTH?

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Under value-based pay environment, providers are held

accountable for costs and outcomes

Difficult to improve health & wellbeing and deliver value

unless we address barriers

Current payment systems do not incentivize approaching

health holistically and in an integrated fashion

Providers serving complex patients often penalized without risk

adjustment

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HEALTH, ACCOUNTABILITY & VALUE

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Bay Area regional Health Inequities Initiative (BARHII). 2008. “Health Inequities in the Bay Area”, accessed November 28, 2012 from http://barhii.org/resources/index.html.

Figure 1

WHAT IS DRIVING THE NEED TO COLLECT DATA ON

THE SOCIAL DETERMINANTS OF HEALTH (SDH)?

How well

do we

know our

patients?

Are services

addressing

SDH

incentivized

and

sustainable?

Are

community

partnerships

adequate

and

integrated?

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Social and Economic

Factors (40%)

Clinical

Care (20%)

Health

Behaviors

(30%)

Physical

Environment (10%)

Project Goal: To create, implement/pilot test, and promote a

national standardized patient risk assessment protocol to assess

and address patients’ social determinants of health (SDH).

PRAPARE:

PROTOCOL FOR RESPONDING TO & ASSESSING PATIENT ASSETS,

RISKS, & EXPERIENCES

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PRAPARE

Assessment Tool

To Identify Needs

Protocol to

Respond to Needs

• Paper Tool

• EHR Templates

• List of Granular

Needs

• ICD-10 Z Codes

• Workflow Diagrams

• Staff Training

Curriculum

• Implementation and

Action Toolkit

• Examples of Interventions

• Guidance on how to build

capacity

• Appendix of Resources

• Guidance on informing

policy and payment

+

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Community Context

Understand Patients

Transform Care

Impact DemonstrateValue

FROM DATA TO PAYMENT: CONNECTING THE DOTS

Upstream

socio-

ecological

factors

impact

behaviors,

access,

outcomes,

and costs

Inquiry &

standardized

data

collection

Under-

stand extent

of patient &

population

complexity

New or

improved

non-clinical

interventions,

enabling

services,

and

community

linkages

Impact

root causes

of poor

health

Improve

outcomes,

patient/staff

experiences

Lower total

cost of care

Negotiate

for payment

change

Ensure

sustainability

of

interventions

Analyze standardized data

Individual Patient

Level

Local Population

Level

State and National

Level

HOW DID WE CREATE PRAPARE?

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Used evidence to

apply domain criteria

Literature reviews of SDH associations with cost and health outcomes

Monitored and/or aligned with national initiatives

• HP2020

• RWJF County Health Rankings

• ICD-10

• IOM on SDH in MU Stage 3

• NQF on SDH Risk Adjustment

Collected existing protocols from the field

• Collected 50 protocols (many not validated)

• Interviewed 20 protocols

• Identified top 5 protocols

Engaged stakeholders for feedback

• Braintrust (advisory board) discussion

• Surveyed stakeholders

• Distributed worksheet to potential users for feedback

Identified

15 Core

Domains

IDENTIFYING CORE DOMAINS

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Critiera:

1) Actionability

2) Alignment with National Initiatives

3) Evidence in Research

4) Burden of Data Collection

5) Sensitivity

6) Stakeholder Feedback

PRAPARE DOMAINS

PRAPARE asks 15 questions to assess 14

core SDH domains.

9 domains already asked for federal

health center reporting (Uniform Data

System) so can be auto-populated

5 non-UDS domains informed by

Meaningful Use Stage 3

PRAPARE has 6 optional domains.

Find the tool at :

http://www.nachc.com/research-data.cfm

UDS SDH Domains

1. Race

2. Ethnicity

3. Veteran Status

4. Farmworker Status

5. English Proficiency

6. Income

7. Insurance

8. Neighborhood

9. Housing

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Core

Non-UDS SDH Domains

10. Education

11. Employment

12. Material Security

13. Social Integration

14. Stress

Optional

Non-UDS SDH Domains

1. Incarceration History

2. Transportation

3. Refugee Status

4. Country of Origin

5. Safety

6. Domestic Violence

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CROSSWALK OF PRAPARE WITH OTHER NATIONAL INITIATIVES

PRAPARE Domain UDS ICD-10 IOM Meaningful

Use (2 and 3)

HP2020 RWJF County

Health

Race/Ethnicity X X X X X

Farmworker Status X

Veteran Status X Seeking

comments

English Proficiency X X X X

Income X X X X X

Insurance Status X X X

Neighborhood X X X X X

Housing X X X

Education X X X X X

Employment X X X X X

Material Security X X X X X

Social Integration X X X X X

Stress X X X X

Selected questions to measure SDH

domains

• Pulled from existing validated questions when possible (few validated questions exist)

Questions Reviewed by

Health Literacy Expert

• To ensure language matched common reading levels

Performed Cognitive Testing on Questions

• Each pilot site performed cognitive testing with at least 10 patients

Pilot Tested Questions

• Revised as necessary after pilot testing

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VALIDATING THE TOOL

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13

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EXAMPLES OF NEXTGEN TEMPLATES

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EXAMPLES OF NEXTGEN TEMPLATES

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WHAT IS THE STATUS OF

PRAPARE?

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TIMELINE OF THE PROJECT

Year 1

2014

•Develop PRAPARE tool

Year 2

2015

•Pilot PRAPARE implementation in EHR and explore data utility

Year 3

2016

•PRAPARE Implementation & Action Toolkit

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Dis

se

min

atio

n

PRAPARE PILOT TESTING IMPLEMENTATION TEAMS AND

ELECTRONIC HEALTH RECORDS

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IN DEVELOPMENT: IMPLEMENTATION AND ACTION TOOLKIT

Categories Examples of Potential Resources to Include

Step 1: Understand the Project Project overview, project framework, defining risk, case studies, FAQs

Step 2: Engage Key Stakeholders Messaging materials, change management guidance

Step 3: Strategize the Implementation Plan Readiness assessment, PDSA materials, 5 Rights Framework, Implementation

timeline, progress reports, legal documents

Step 4: Technical Implementation PRAPARE paper assessment, data documentation, EHR templates, sample

data dictionaries, data specifications, data warehouse and retrieval strategies,

guidelines for using design and requirements documents

Step 5: Workflow Implementation Workflow diagrams, data collection training curriculum, lessons learned and

best practices

Step 6: Understand and Report Your Data Reporting requirements, sample database, sample data outputs, sample data

analyses and reports, cross-tabulating data, evaluation protocol, population-

level planning, guidelines for data integration

Step 7: Act on Your Data Strategy for detecting risk, report on best practices and processes for using SDH

data, examples of SDH interventions, SDH response codes, linking to enabling

services codes

Step 8: Use Your Data to Drive Payment and

Policy Transformation

Strategy to engage payers, funding SDH efforts, data visualization templates

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PRAPARE IS A NATIONAL MOVEMENT!

• Health centers in 8

states are either already

using PRAPARE or are

planning to begin using

PRAPARE in 2016

• Health centers, state

associations, regional

networks, and other

health care

organizations in 20+

other states interested

in using PRAPARE

Use and Interest in PRAPARE

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HOW CAN PRAPARE BE USED AT

YOUR ORGANIZATION?

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• How will tool be administered to the patient to ensure that it accurately identifies the SDH the patient may have? Right Information

• Who will collect the data and who will address the social determinants identified? Right Person

• How will resource information be organized so that it is readily available and standardized for all?

Right Intervention Format

• How is the appropriate care team member notified to address the SDH identified? Right Channel

• When in the patient visit does it make sense to administer the tool and when is the best time to address identified SDH?

Right Time in Workflow

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IMPLEMENTING PRAPARE:

USING THE FIVE RIGHTS FRAMEWORK

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SAMPLE WORKFLOWSHealth

Center

Who Where When How Rationale

CHC #1 Non-clinical staff

(enrollment

assistance)

In exam room Before provider visit Administered PRAPARE with

patients who would be

waiting 30+ mins for

provider

Provided enough time to discuss SDH

needs

CHCs #2 Nursing staff

and/or MAs

In exam room Before provider

enters exam room

Administered it after vitals

and reason for visit. Provider

reviews PRAPARE data and

refers to case manager

Wanted trained staff to collect sensitive

information. Waiting area not private

enough to collect sensitive info

CHC #3 Non-clinical staff

(patient navigators,

patient advocates,

and community

health workers)

In patient

advocate’s

office

After clinical visit

when provider refers

patient to patient

navigator

Patient advocates

administer it and then can

relay to provider in office

next door.

Wanted same person to ask question and

address need. Often administer

PRAPARE with other data collection effort

(Patient Activation Measure) to assess

patent’s ability and motivation to respond

to their situation.

CHC #4 Medical Assistants In exam room Before provider MAs administer PRAPARE

while patient is roomed but

before provider.

Want to get patient in to exam room as

quickly as possible. However, often don’t

finish because provider comes in to exam

room.

CHC #5 Care Coordinators No wrong door

approach

No wrong door

approach, but mostly

as care coordinators

complete chart

review and HRA

Allows staff to address similar issues in

real time that may arise from both

PRAPARE and HRA

WHAT HAVE WE LEARNED FROM

PRAPARE?

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WHAT WE’VE LEARNED FROM PILOT TESTING

Easy to use:

On average, takes ~9

minutes to complete

form

Emotional Toll on

Staff

Staff find value in the

tool: Helps them better

understand patients

and build better

relationships with

patients

Patients appreciate

being asked and feel

comfortable answering

questions

Identifies New Needs,

Often Leading to New

Community Partnerships

Made minor revisions

to tool based on pilot

testing feedback

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COMMON CHALLENGES ENCOUNTERED WHEN USING

PRAPARE AND SOLUTIONS

Challenge: Staff and Patients Don’t Understand Why

Doing PRAPARE

Solution: Use short script to explain to staff &

patients why health center is collecting this

information. Message around better understand

patient and patient’s needs to provide better care

Challenge: Have too much going on now to add

another project

Solution: Don’t market PRAPARE as new big

initiative but as project that aligns with other work

already doing (care management, ACO, enabling

services, etc)

Challenge: How do we

implement this without

increasing visit time?

Solution: Find “Value-Added”

time, whether in waiting room,

during rooming process, or

after clinic visit

Challenge: Fitting PRAPARE into

Workflow

Solution: Incorporate into other

assessments to encourage

completion (Health Risk

Assessment, Depression Screening,

Patient Activation Measure, etc)

Challenge: Inability to Address SDH

Solution: Message “Have to start

somewhere and do the best we can

with what we have. Collecting

information will help us figure out

what services to provide.”

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PERCENT OF PATIENTS WITH NUMBER OF SDH

“TALLIES”

0%

5%

10%

15%

20%

25%

30%

35%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Tally Score

Alliance/Iowa Waianae New York Oregon Total3 CHCs 1 CHC 2 CHCs 1 CHC 7 CHCs

N = 2,694 patients for

all teams

DATA RESULTS

SDH risks vary by community

Most common risks:

High stress

Having less than a high school education

Uninsured

Unemployed

Preference for language other than English

But, patients are very socially integrated,

Half of patients in our pilot test see people that they care about more

than 5+ times a week.

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MATERIAL SECURITY

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Food Clothing Utilities Rent/mortgage

payment

Transportation Child care Medicine or

medical care

Health

Insurance

Phone

Alliance/Iowa Waianae New York Oregon All Teams

N = 2,980 for all teams

CORRELATION BETWEEN SDH FACTORS AND HYPERTENSION:

ALL TEAMS

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Tally Score

% of POF % of the tally score with Hypertension

r = 0.61

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USING DATA ON THE SOCIAL

DETERMINANTS OF HEALTH

HOW PRAPARE DATA HAS BEEN USED TO IMPROVE CARE

DELIVERY AND HEALTH OUTCOMES

Ensure prescriptions and treatment plan match

patient’s socioeconomic situationBuild services in-house for same-day use

as clinic visit (children’s book corner,

food banks, clothing closets, wellness

center, transportation shuttle, etc)

Build partnerships with local community based

organizations to offer bi-directional referrals and

discounts on services (ex: Iowa transportation)

Create risk score to inform risk

adjustment

Inform both Medicaid and Medicare ACO

discussions and care management policies

Better Understand

INDIVIDUAL

Patient’s

Socioeconomic

Situation

Better Understand

Needs of Patient

POPULATION

Drive STATE and

NATIONAL Care

Transformation

Refer patients to needed social services, whether

in-house or through community partnership

Improve Community Resource Guide to

ensure accuracy and appropriateness

Inform advocacy efforts related to local

policies around SDH

Streamline and expand care management plans to

better allocate resources to areas most in need

Inform payment reform and APM discussions with

state agencies (e.g., Medicaid) on caring for

complex patients 34

Guide policies to incentivize integrated

care with social services

Guide work of local foundations to pay

for non-clinical services and partnerships

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Few

resources

Many

resources

He

alt

h C

en

ter

Re

so

urc

es

Local Community Resources

Substantial resources within

the health center

Limited resources in

the local community

Substantial resources

within the health center

Substantial resources in

the local community

Limited resources in

the local community

Limited resources

within the community

health center

Substantial resources in

the community

Limited resources within

the health center

ASSESS WHERE YOU ARE IN TERMS OF RESOURCES

(PEOPLE, PROCESSES, TECHNOLOGY)

NEED

Standardized data on patient

risk

RESPONSE

Standardized data on

interventions

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BOTH are necessary to demonstrate health center value

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AAPCHO DATA COLLECTION PROTOCOL:

THE ENABLING SERVICES ACCOUNTABILITY PROJECT

CATEGORY CODE Minutes

CASE MANAGEMENT ASSESSMENT CM001

CASE MANAGEMENT TREATEMENT AND

FACILITATION

CM002

CASE MANAGEMENT REFERRAL CM003

FINANCIAL COUNSELING/ELIGIBILITY

ASSISTANCE

FC001

HEALTH EDUCATION/SUPPORTIVE

COUNSELING

HE001

INTERPRETATION IN001

OUTREACH OR001

TRANSPORTATION TR001

OTHER OT001

Enabling Services

Accountability Project

(ESAP)

The ONLY standardized

data system to track

and document

non-clinical enabling

services that help

patients access care.

CONCEPTUAL FRAMEWORK

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Appropriate Care

(For health condition in question,

for example, # of doctor visits,

exams/tests levels…)

Health Outcomes

(For example, ideal

outcomes, reduced

complications, ED visits,

etc..)

Enabling Services & other non-clinical interventions

Social Determinants of

Health

(PRAPARE Domains:

Race/ethnicity, poverty

employment, English

proficiency, etc..)

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NEXT STEPS

NEXT STEPS

Complete Implementation &

Action ToolkitPhase IISpread

2016

Including:

* Free EHR Templates—by

May

* Training Materials—by

this summer

* Model Interventions to

Address the SDH—by this

summer

Including:

* Standardized data on

Interventions

• National PRAPARE

Learning Network

• State Based Action groups

* Validation

* Translation

* Pediatric PRAPARE Tool

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PRAPARE resources will be posted at www.nachc.com/research

PRAPARE Tool

Implementation steps and timeline

Data Documentation

AAPCHO’s ESAP technical and other resources at http://enablingservices.aapcho.org.

PRAPARE info and listserv signup: Michelle Jester, mjester@nachc.org

AAPCHO ESAP technical assistance: Tuyen Tran, ttran@aapcho.org

RESOURCES AVAILABLE TO YOU

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Stay tuned for date and time!! Email Michelle and mjester@nachc.org if interested

Will cover the following:

Steps to implement the NextGen template in another clinic’s EHR system

The particulars of using the NextGen PRAPARE template

A health center’s experience in redesigning or modifying workflow to collect and respond to the

data on social determinants

How the NextGen PRAPARE template can expedite the reporting and aggregation of data and

be used for patient and population-level interventions

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PRAPARE NEXTGEN-SPECIFIC WEBINAR

4/19/2016

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QUESTIONS AND DISCUSSION