www.effectivepractice.org

EMR – Integrated Solution in Primary Care to Screen and Support those Living in Poverty

Presented by:Dr. Mario Elia, London Lambeth Medical Clinic

Claire Stapon, Centre for Effective Practice

Faculty/Presenter Disclosures

• Faculty/Presenter: Dr. Mario Elia (Faculty)

– Relationship with Commercial Interests: Physician Advisor to TELUS Health for Rare Diseases Dashboard

• Faculty/Presenter: Claire Stapon (Presenter)

– Relationship with Commercial Interests: None

Disclosure of Commercial Support

• No commercial support

• Potential for conflict(s) of interest: None

Mitigating Potential Bias

• Content of this presentation has been reviewed by a panel of physician and nurse peers to ensure that it remains unbiased and has no commercial representation

Poverty & Health

• In Ontario, approximately 20% of families, or 1.57 million people, live in poverty (Government of Ontario, 2018)

• 50% of population health determined by social & economic environment (CMA, 2015)

• Large body of evidence linking low income to individual health

Poverty is a risk factor for many

conditions

Diabetes

COPD

Toxic Stress

Mental Illness

Cancer

Arthritis

Asthma

Ref: Lightman 2005, Lightman 2009, Bierman 2009, Emerson 2009

Primary care providers well-situated to act as entry point to social service supports for individuals living in poverty

EMR-integrated Strategy to Screen and Identify Poverty in Primary CarePurpose:

• Develop EMR-integrated intervention to screen and identify poverty in primary care to enable and support PCP intervention for patients affected by poverty

• Pilot tool to understand impact/feasibility

Funding: Trillium Foundation Grant, funded by the Government of Ontario

Who Was Involved• Project Lead: Centre for Effective Practice (CEP)

• Clinical Leads: Drs Gary Bloch and Julia Orkin

• Partners: – Ontario 211 & CognisantMD– Justin Presseau/Ontario Health Research Institute

(independent evaluator)

• Pilot Sites: – Dr. Mario Elia, London ON– City of Lakes FHT, Sudbury ON– Two Rivers FHT, Cambridge ON– Kindercare Pediatrics, Toronto ON

About the CEPThe Centre for Effective Practice (CEP) engages

with healthcare providers throughout its processes and creates

solutions based on best evidence that can be adapted in providers’

local contexts.

Project Approach

Intervention (2 month pilot)

OCFP Treating Poverty Workshop

Baseline Survey

Follow-up surveyPost-intervention

interviewsEMR/OCEAN Data

Extraction

4 sites selected for pilot testing across Ontario

Evaluation

PilotTool Developed and Tested

Intervention Overview

Patient questionnaire

administered via OCEAN tablet

Provider Point-of care EMR

enabled intervention

Patient provided with tailored list

of community resources

1 2 3

1. Patient Questionnaire

Validated pre-screener question for all patients:

Do you have difficulty making ends meet at the end of the month?

1. Patient Questionnaire

1. Patient Questionnaire

For patients that select ‘Yes’, additional questions appear

2. EMR-Enabled Intervention

2/9/2018 DRAFT CEP Poverty Tool

https://ocean.cognisantmd.com/questionnaires/preview/QuestionnairePreview.html?ref=draft_cep_poverty_to&siteNum=2648 1/2

View XML

Yes No Don't know Prefer not to answer

No Yes Not Sure

No Yes

No Yes Not Sure

No Yes

No Yes Not Sure

No Yes

No Yes Not Sure

There are many types of income benefits available to Canadians, and improving

income can help improve health. We are asking all patients at this clinic to

complete the following survey. By answering these questions, you can help your

provider determine if there are income benefits and supports that you may be

eligible for.

Participation is optional and your answers will not impact your usual standard of

care.

Do you ever have difficulty making ends meet at the end of the month?

Have you filled out and sent in your income tax forms for the last year?

Are you a parent or legal guardian to children under 18 years of age?

Do you receive the child benefit on the 20th of every month?

Are you a person of Indigenous heritage/descent/ancestry, that is, First Nations,

Inuit, or Métis?

Are you a social assistance recipient (e.g. Ontario Disabilities Support Program, Ontario

Works, etc.)?

Do you live with a mental or physical disability?

Do you receive Old Age Security (OAS) and Guaranteed Income Supplement (GIS)?

Do you have any other concerns about income that you would like to ask your provider?

• Custom form generated based on responses

2. EMR-Enabled Intervention

2. EMR-Enabled Intervention

2. EMR-Enabled Intervention

3. Tailored List of Community Resources

2/9/2018 DRAFT CEP Poverty Tool

https://ocean.cognisantmd.com/questionnaires/preview/QuestionnairePreview.html?ref=draft_cep_poverty_to&siteNum=2648 1/2

View XML

Yes No Don't know Prefer not to answer

No Yes Not Sure

No Yes

No Yes Not Sure

No Yes

No Yes Not Sure

No Yes

No Yes Not Sure

There are many types of income benefits available to Canadians, and improving

income can help improve health. We are asking all patients at this clinic to

complete the following survey. By answering these questions, you can help your

provider determine if there are income benefits and supports that you may be

eligible for.

Participation is optional and your answers will not impact your usual standard of

care.

Do you ever have difficulty making ends meet at the end of the month?

Have you filled out and sent in your income tax forms for the last year?

Are you a parent or legal guardian to children under 18 years of age?

Do you receive the child benefit on the 20th of every month?

Are you a person of Indigenous heritage/descent/ancestry, that is, First Nations,

Inuit, or Métis?

Are you a social assistance recipient (e.g. Ontario Disabilities Support Program, Ontario

Works, etc.)?

Do you live with a mental or physical disability?

Do you receive Old Age Security (OAS) and Guaranteed Income Supplement (GIS)?

Do you have any other concerns about income that you would like to ask your provider?

Patient survey responses + patient postal code

Community Resources from Ontario 211 website

Custom handout

3. Tailored List of Community Resources

Future Poverty Data Extractions

• Intervention provides data to inform future poverty-related initiatives

• Custom vital created by EMR tool can easily be searched in EMR to identify patients previously screened and flagged as being at risk

One Site’s Experience

• This simple intervention was truly transformative in my practice

• Went from not screening for poverty at all, to having rich data set that I can act on now, and in the future

• Was able to link dozens of patients to resources they had been eligible to receive for years

• Very little negative impact in terms of day-to-day workflow

Evaluation Overview

Objectives: Understand feasibility & potential impact of EMR-integrated poverty intervention

Outcomes of Interest

• # patients screened, identified, and referred to community services at eachpractice after the introduction of the EMR-enabled screening tool;

• Impact on primary care staff ’s knowledge, attitudes and poverty screening behaviours;

• primary care staff ’s experienced barriers and enablers to implementation

Evaluation: Results

4,517patients were screened in the waiting room for risk of living in poverty

30% of those patients were

provided with customized resources/ referral to community

supports

12% of patients screened were identified as at risk of poverty (20%

if outlier site removed)

Variability by Site

Site 1 Site 2 Site 3 Site 4

14%

86%

6%

94%

22%

78%

23%

77%

Figure 3. Patient Response to Screening Question, by Site (”Do you ever have difficulty making ends meet?”)

Responded “No”, “Don’t know, or “Prefer not to answer”

Responded “Yes”

Impact on Provider Knowledge/Skills/Behaviour

Post-intervention: sites reported higher levels of knowledge, skills and resources for referring and intervening with patients identified as at risk of poverty

Impact on Behaviour

Pre-intervention Only a minority of patients were being provided with resources and/or referrals related to poverty.

Post-Intervention Sites reported providing resources and referrals to twice as many patients on average in a given two-week period(with one site showing substantial increase, from 4 to 20 every 2 weeks)

Enablers, Barriers, and Learnings

• Overall, all sites responded positively to intervention and felt that it was valuable

– Results showed substantial # of patients at risk for poverty in primary care

– EMR-integrated tool supports healthcare providers in poverty screening and intervening at-risk patients;

• However, post-intervention results also showed that half of provider respondents reported lacking confidence in providing patients with sufficient resources to meet patients’ needs

– Resource handout can be improved

Conclusion

• The intervention:

– Improved provider motivation to screen for poverty

– knowledge among providers about benefits programs and social services

– Increased number of patients screened and connected to benefit programs and community supports

• Findings from the pilot will:

– Contribute to body of knowledge to support other poverty interventions

– help inform refinements to the tool to support wide-scale uptake

For more information…

For more information on the initiative and the tool, visit

thewellhealth.ca/poverty

• Here you will find:

– The paper-based Poverty Tool (via downloadable PDF).

– Modified version of the EMR-integrated tool, for OCEAN users (can also be accessed from: tablets, Ocean patient screens, eRequests and the EMR)

– Updates and additional details.

• Also in the works:

– Potential opportunities to make modified versions of the tool available for all EMRs.

Check out our website or follow us on Twitter (@CEPHealth) for the latest updates.

References

• Bierman AS, Ahmad F, Angus J, Glazier RH, Vahabi M, Damba C, et al. Burden of illness. In: Bierman AS, editor. Project for an Ontario women’s health evidence-based report: Volume 1. Toronto, ON: Echo – Improving Women’s Health in Ontario; 2009 [cited 2015 Aug 29]; 1-143.

• Canadian Medical Association. Policy: Health Equity and the Social Determinants of Health: A Role for the Medical Profession. CMA Policy, 2013.

• Emerson, E. (2009). Relative child poverty, income inequality, wealth, and health. JAMA, 301(4), 425-6.

• Lightman E, Mitchell A, Wilson B. Poverty is making us sick: a comprehensive survey of income and health in Canada. Toronto: Wellesley Institute; 2008 Dec [cited 2015 Aug 29]; 1-38.

• Lightman E, Mitchell A, Wilson B. Sick and tired: the compromised health of social assistance recipients and the working poor in Ontario. Toronto: Wellesley Institute; 2009 Feb [cited 2015 Aug 29]; 1-33.

• Ontario’s Poverty Reduction Strategy: Realizing Our Potential, 2014-2019. Government of Ontario (2014). [cited 2018m Sept 1].

Thank you.