Social Needs/SDOH

This affinity group includes @Tri_City @Serve_the_People @Santa_Rosa @North_County @LA_County. Please feel free to share your group’s progress and updates below!

We have the PRAPARE tool with our NG, and our team has gotten training, so we are ready to launch and interview our non-compliant diabetic patients. What is the status of everyone else?

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Hi Diana,

Our team is actively involved in the process to implement an SDOH tool. We convene regularly with multi-disciplinary departments to create a broader awareness with emphasis on targeting those staff directly involved in the process.
Thanks!

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Out team will implement the first of the SDOH PRAPARE survey end of April. We have made a binder of 3-5 resources for each category in the Survey. Linkages will be done after surveys are done and what needs for social linkages are identified. Patients will be linked to resource at a follow- up appt or phone call. We will encourage patient for face to face appt with a health coach to provide resources. We are excited and hoping all goes well!

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Hi all! Based on the doodle poll, Tuesday, April 30 at 12pm works the best overall for our first social needs affinity group meeting. Here is the link to the Zoom line: Launch Meeting - Zoom

A couple of quick reminders:

  • I sent out a calendar invite to everyone on this email, but of course decline if you can’t make it or have delegated attendance to others in your group. As a reminder, it would be * ideal * to have at least 2 individuals from each team participate, and more are welcome.

  • I’ll be facilitating and there’s nothing you need to do in advance, just show up!

  • We’ll be using Zoom and I’ll be using my camera, and it would be great if others (as you are able) plan to use yours too so we can see each other.

Here’s an agenda to get started during our first virtual meeting:

  1. Welcome & Housekeeping
  2. Revisiting the Affinity Groups: What are they & how do we participate?
  3. Team Introductions: Each team in the affinity group will be asked to share:
  • Overview of the goal of their project for Year 2
  • Any key questions they have for the group
  1. Open Time: Q&A among affinity team members
  2. Closing:
  • Feedback: I like, I wish, I wonder
  • Next Steps: Can we get someone to volunteer to schedule & facilitate the next meeting?

Are there other agenda items you would like to include? Do you have any questions for your fellow AG members at this time? Let me know!

We’re currently creating a paper form of the PRAPARE so that patients can fill it out on their own. We found the actual PRAPARE form to be confusing and not much white space. We’ve added an intro paragraph about how we ask these questions of everyone so that we can help link to resources. We haven’t changed any of the wording, but changed the layout so that they have any “yes” answers on one side and “no” answers on the other side. That way when an MA is looking at it they can quickly see if there are any things they need to address. We’re testing a couple of iterations with patients to see which they prefer. Then we’re moving to process flow mapping to nail down what the ideal workflow would be.

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Hi all!

Sorry for the late response here. Our team is in the process of strategizing around PRAPARE implementation. Our next step is developing a survey to assess staff and patient awareness around SDH’s. We’re actually going to present the idea of a patient advisory board to our group medical visit patients on Wednesday 5/1. I’ll definitely update you all on some of their thoughts! Look forward to hearing from you all.

Best!

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Dear Social Needs Affinity Group @Santa_Rosa @Tri_City @LA_County @Serve_the_People @North_County,

It was great to talk with you all on Tuesday! The notes from our meeting today are attached, and the next steps I captured are as follows:

  • Team agreed to meet again in July. Next Steps:
    • Megan to send a Doodle Poll to schedule our next c all.
    • Trushna @Trushna-TriCity & Padmaja @pmagadala from Tri-City volunteered (thank you!) to facilitate.
    • Megan will send out resources discussed on the call.
  • Based on popular topics from our conversation, I would suggest the following topics for our next call:
    • Screening: What are your updates regarding decisions you’ve made and/or tools you’ve piloted to assess for social needs?
    • Staff Buy-in & Training: How are you getting buy-in from leadership and staff with this work? What’s effective and what’s not? What internal or external training are you providing staff to do this work well?
    • Tracking & Closing the Loop: How are you planning to track referrals outside of organization and make sure you close the loop?
  • Teams will post any resources they would like to share / review ahead of the call. In particular, it would be great to see the changes to PRAPARE and the intro script your team is working on at Santa Rosa, Michelle @MichelleG_SRCH.

Thank you everyone! Let’s start leveraging this forum with any questions or insights you’d like to share!PHLN Social Needs Affinity Group Notes.docx (17.6 KB)

Here are a link to the resources we discussed on our call:
@cathy.sakansky @sarahmi @gheredia @MichelleG_SRCH @jamie.williams @LA_County @Trushna-TriCity @pmagadala

Social Needs Screening Tool Comparison: SIREN has compiled information from several of the most widely used social health screening tools for stakeholders interested in comparing these instruments. The summary tables include information on intended population or setting, domains/topics covered, and number of questions dedicated to each domain. Here’s the link: Research on Integrating Social & Medical Care | SIREN | Screening Tools Comparison

Community Resource Referral Platforms Guide: The SIREN team at UCSF has developed a guide that explores the landscape of community resource referral platforms, the experiences of early adopters, features and functionalities of these technologies and lessons learned and recommendations on how to implement a community resource referral platform.

ROOTS Lessons Learned & Case Studies : CCI ran a yearlong program with seven teams the spent time testing and clarifying the role that health care safety net organizations can play in addressing the social determinants of health through our ROOTS program.

Training: Two resources that I mentioned on the call were around empathic inquiry. Elevation Health Partners did a webinar for us on this, specifically in the context of screening for social needs, and they also offer trainings. The Oregon Primary Care Association (OPCA) has also been doing a lot in Oregon.

In addition to Empathic Inquiry, here’s a copy of La Clinica’s @La_Clinica PRAPARE Training Manual: http://www.nachc.org/wp-content/uploads/2019/01/PRAPARE-Training-Manual-v3-FINAL-06.05.17_La-Clinica-de-la-Raza.pdf

Sample Workflows

OPCA has developed 4 workflow alternatives to help clinical team members screen patients for SDH; they include:

We also hosted a webinar with Dr. Rishi Manchanda from Health Begins, featuring Hayward Wellness called “Optimizing the Flow of Information and Work for Social Needs.” Here’s the link to the recording and slides: Optimizing Flow of Information and Work for Social Needs - CCI

Finally, here are resources from NACHC about workflows considerations, specifically around PRAPARE: http://www.nachc.org/wp-content/uploads/2019/04/NACHC_PRAPARE_Chpt5.pdf

Hi CCI Team!

Appreciate the notes captured from the meeting.

In reference to the topic recommendations for the next meeting, tracking and closing the loop is of great interest to learn from others as we continue to plan and implement our process.

Thank you,
Cathy

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Hi all,

Very nice to catch glimpse of everyones journey. I second North County’s interest in closing those loops as this is a point of interest for us at STP.

In reference to empathy, I look to @brubino here for guidance as STP aims to train staff around empathy and SDH’s. Barbara if you would be kind enough to share your experience on Empathic Inquiry and SDH’s with Elevation Health Partners. Please do feel free to reach out via email as well! gheredia@servethepeoplechc.org

Thank you,
George

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Hi everyone!

Based on the doodle poll, Tuesday, July 2 at 12pm works the best overall for our next social needs affinity group meeting. As a reminder, it would be * ideal * to have at least 2 individuals from each team participate, and more are welcome.

A couple of quick reminders:

  • I’m sending out a calendar invite to everyone on this email, but of course decline if you can’t make it or have delegated attendance to others in your group.
  • Our friends Trushna and Padmaja from Tri-City will be facilitating the call and I’ll be doing some light notetaking.
  • We’ll be using Zoom and I’ll be using my camera, and it would be great if others (as you are able) plan to use yours too so we can see each other.

Based on popular topics from our first conversation, I would suggest the following topics for our next call:

  1. Screening: What are your updates regarding decisions you’ve made and/or tools you’ve piloted to assess for social needs?
  2. Staff Buy-in & Training: How are you getting buy-in from leadership and staff with this work? What’s effective and what’s not? What internal or external training are you providing staff to do this work well?
  3. Tracking & Closing the Loop: How are you planning to track referrals outside of organization and make sure you close the loop?

Are there other agenda items you would like to include? Do you have any questions for your fellow AG members at this time? Let me know!

Thanks everyone,
Megan

Hi Trushna,

I’m curious, who in your organization, is completing the SDOH questions? We have a SDOH template in Nextgen EMR but we are not sure who should be completing this questionnaire as it is really lengthy so we are looking at what other organizations are doing. We were thinking of having the Care Coordinators ask these questions but they are also limited in time with the patients.

Thanks in advance for your input!

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Hello,

At this time, we are using the SDOH PRAPARE tool for diabetes pts who attend our DM class education. We are trying to measure that if we are able to address any
SDOH for our patients and link them to services that they may improve their health and mainly their Diabetes. A combination of education with nutrition and linkage to services. We hope to see a change inpatients HbA1C.

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@Trushna-TriCity I’m sorry, i’m not extremely familiar with the SDOH PRAPARE. Who administers the questions during the DM class?

Hello Gabriela,

The health coaches doing the class. We actually give it to the patients attending and then at the end of the class go through the survey to review with patient
to ensure completed and if they needed help with filling it out. I hope this helps.

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Hi @LA_County, @Tri_City, @Santa_Rosa, @Serve_the_People, and @North_County,

A friendly reminder that we have our 2nd Social Needs Affinity Group meeting tomorrow on Tuesday, July 2nd from 12-1pm.

Proposed Agenda Topics:

  1. Round Robin – Updates from each team & challenges/questions that are top of mind
  2. Group Discussion:
  • Screening: What are your updates regarding decisions you’ve made and/or tools you’ve piloted to assess for social needs?
  • Staff Buy-in & Training: How are you getting buy-in from leadership and staff with this work? What’s effective and what’s not? What internal or external training are you providing staff to do this work well?
  • Tracking & Closing the Loop: How are you planning to track referrals outside of organization and make sure you close the loop?

3. Next steps & meeting logistics

A couple of resources that I also wanted to share:

  1. Updated PRAPARE Implementation & Action Toolkit: http://www.nachc.org/research-and-data/prapare/toolkit/
  2. Upcoming Webinar (July 18 at 11am): Examining the Validity of Clinical Social Risks Screening Tools: Meeting Registration
  3. Kaiser Permanente & Unite Us Announcement: Kaiser Permanente Launches Social Health Network to Address Social Needs on a Broad Scale
  4. Archived Webinar: Community Resource Referral Platforms: Lessons from Early Health Care Adopters: Research on Integrating Social & Medical Care | SIREN | Community resource referral platforms - Lessons from early health care adopters

Thank you @Tri_City @LA_County @North_County @Serve_the_People @Santa_Rosa for attending the Social Needs Affinity Group call yesterday. And a special thank you to @pmagadala and @rtanglao from Tri-City for facilitating! Attached are some brief minutesNotes from AG Social Needs Call 7.2.19.docx (17.7 KB) ; it was great to have the opportunity to dive deeper into the work that Tri-City, SRCH, and Serve The People are doing.

@MichelleG_SRCH, could you post the revised version of your PRAPARE paper tool?

We talked about scheduling our next call in early to mid-August, and to devote time to hearing updates from North County & LA County.

Here are the potential dates & times that I am proposing:

  • Thursday, August 8 @12pm
  • Wednesday, August 14 @12pm
  • Thursday, August 15 @ 12pm
  • Friday, August 16 @ 12pm

Either let me know below what works for your team OR fill out this quick doodle poll by EOD Monday, July 8: Doodle - Make meetings happen

Finally, I will be on vacation July 20-August 5, but the rest of the CCI team will be available if you have any questions. And if you have any Japan-related suggestions, please let me know!

Thank @Santa_Rosa team for sharing your revised versions of the PRAPARE template, both the English and Spanish versions.

SRCH PRAPARE Template 6_5_19[1].docx (111.9 KB)

SRCH PRAPARE Template 6_5_19_Spn.docx (112.4 KB)

Hi everyone @Tri_City @LA_County @North_County @Serve_the_People @Santa_Rosa
I just sent a calendar invite for your next call, on August 14th 12-1pm.

To join the call please join:
Call-in: 408-638-0968, meeting ID: 415 561 6666
1-click audio: 4086380968,4155616666#
https://zoom.us/j/4155616666