Overview

This pilot study assessed the feasibility of implementing EHR tools for collecting, reviewing, and acting on patient-reported social determinants of health in three community health centers, and found that substantial barriers to adoption exist but such interventions may be feasible and beneficial.

Organization Name

Oregon Community Health Information Network (OCHIN)

Organization Type
  • Community health center
  • Community health system
  • Community outpatient clinic
  • FQHC
National/Policy Context

  • According to the World Health Organization, social determinants of health (SDoH) are the circumstances in which people are born, grow up, live, work and age. Specific determinants, defined by the Center for Medicaid and Medicare Services, are food insecurity, housing instability, transportation, interpersonal violence, and unmet utility needs.
  • SDoH are a big contributor to poor health outcomes, and there are widespread unmet social needs across the members of the community.
  • SDoH screening has been attempted across many healthcare settings, specifically in community health centers (CHCs), where patient populations are vulnerable to social and economic factors that contribute to poor health. Standardized SDoH screening documentation in EHRs has been endorsed by professional and medical organizations in the United States, but has not been widely implemented or formally evaluated.

Local/Organizational Context

This study was conducted via OCHIN, in close communication with staff at each CHC to help adjust the SDoH EHR screening tool to facilitate its use and maximize potential benefits.

Patient Population Served and Payor Information

  • Patients are primarily publicly insured or uninsured, and aged < 65 years old.
  • 10-31% of patients are non-white, and 10-30% are of Hispanic ethnicity.

Leadership

This study was led by Rachel Gold, PhD, MPH of Kaiser Permanente Center for Health Research and OCHIN; Arwen Bunce, MA of Kaiser Permanente; Stuart Cowburn, MPH of OCHIN; Katie Dambrun, MPH of OCHIN; Marla Dearing of OCHIN; Mary Middendorf of OCHIN; Ned Mossman, MPH of OCHIN; Celine Hollombre, MPH of Kaiser Permanente; Peter Mahr, MD of Multnomah County Health Department; Gerardo Melgar, MD of Cowlitz Family Health Center; James Davis of Kaiser Permanente; Laura Gottlieb, MD, MPH of UCSF; Erika Cottrell, PhD, MPP of OCHIN.

Research + Planning

  • This study was approved by the Kaiser Permanente Northwest Institutional Review Board.
  • Planning for this intervention required developing the SDoH EHR screening tool, discussed below.
  • The following SDoH domains were included:
    • Financial resource strain
    • Housing insecurity
    • Food insecurity
    • Intimate partner violence
    • Inadequate physical activity
    • Social isolation
    • Stress
  • The tool was subsequently modified based on input from clinic staff, specifically to add a “no follow-up required” referral option and to add a question to the questionnaire asking if the patient wanted assistance with SDoH-related needs.
  • Clinics had to determine who would be screened initially to test workflows prior to expanding the intervention:
    • Clinic A: first randomly chose a few patients, then added all new patients and those with completed annual insurance reauthorizations, and finally added patients receiving care coordination, HIV services, and/or behavioral health services.
    • Clinic B: first screened patients in diabetes and Hepatitis C case management programs, then added patients > 65 years old.
    • Clinic C: first screened new patients seen by a single provider, addressed barriers related to staff access/knowledge of the tools, then adopted screening clinic-wide.

Tools or Products Developed

  • SDoH data tools for documenting and summarizing SDoH screening results and making referrals on the EHR were based on the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE), a tool used to assess social determinants of health.
    • Data collection tool: 14 SDoH screening questions (Appendix 1. SDoH Screening Questions) based on PRAPARE and National Academy of Medicine recommendations.
      • Data could be collected in data-entry flowsheets accessible by clinic staff, in printed forms for patients to complete, or completed on an online portal by patients prior to their visit.
    • SDoH Summary Tools (on EHR): The patient’s most recent SDoH data is displayed on the EHR.
    • SDoH Data Rosters: Added SDoH data to EHR’s panel management tools to identify patients who 1) had a pending visit, and could be prompted to complete the SDoH screening pre-appointment, 2) had a positive SDoH screen and needed follow up, 3) were due for SDoH screening.
    • Problem List: Created new SDoH class of problem list diagnoses so EHR users could manually categorize SDoH diagnoses in the problem list.
    • SDoH Referral Tools:  Created preference lists of local resources, in conjunction with participating CHCs, so clinic staff could discuss resources to address patients’ specific SDoH needs.

Training

  • All staff members participating in the study received 2 training session prior to releasing the tool. This training consisted of written materials explaining SDoH, the SDoH data tools, and paper versions of the SDoH questionnaire.
  • Training varied by site:
    • Clinic A held an all-staff training led by the Medical Director. The RN quality coordinator (RNQC) provided suggested workflows and one-on-one training to outreach staff. The Medical Director created SDoH-related activity tracking reports, which were reviewed regularly by the RNQC who checked in with clinic staff as needed.
    • Clinic B discussed the intervention briefly at staff meetings, and provided one-on-one support for relevant staff members (i.e. CHW) who would be heavily involved in the screening.
    • Clinic C had multiple team meetings with members of the pilot team to discuss and develop workflows, which were later shared during an all-staff meeting prior to clinic-wide intervention implementation.

Tech Involved
  • Epic
Team Members Involved
  • MAs
  • NPs
  • PAs
  • Physicians
  • Social Worker
Workflow Steps

  • Front desk staff gave SDoH screening form to designated patients, who handed the completed form to an MA.
    • All 3 clinics principally used paper-based SDoH screening, requiring a data entry workflow step.
  • After these initial steps, workflows varied by clinic:
    • Clinic A: Patients with time-sensitive positive screening results, such as interpersonal violence or social isolation, were handed off to the nurse care coordinator for further assessment and support. All other patients’ forms were placed in outreach staff person’s mailbox. This person was then responsible for entering data into the EHR, identifying community resources, and creating referrals. Referrals were made using the SDoH referral tool, which linked an SDoH-related diagnosis code in the EHR to community services.
    • Clinic B: Form was handed to the nurse case manager or behavioral/wellness coaches. Some staff entered data into the EHR, spoke with patients, and made community resource referrals. Others delegated this process to behavioral/wellness coaches or CHWs.
    • Clinic C: MA immediately entered the data into the EHR. Provider then reviewed the SDoH Summary while seeing the patient. If SDoH screening was positive, provider made an internal referral to CHW who discussed options with patients and made specific SDoH referrals.

Where We Are

  • This intervention lasted from June 2016-July 2017.
  • The clinics continue to utilize the SDoH EHR screening tools.

Outcomes

  • Patient Outcomes:
    • SDoH data were collected in 1,130 patients, representing 4-18% of adult patients with an ambulatory visit at pilot clinics during the study period.
    • 97-99% patients indicated a potential SDoH need in ≥ 1 SDoH domain.
    • Not all patients who screened positively requested help: at Clinics A and B, 15% and 21% of patients, respectively, requested SDoH-related help. This data was not collected for Clinic C.
    • In total, among patients who screened positively, 19% received an SDoH-related referral.
  • Clinician or Patient Satisfaction
    • Clinics have independently chosen to continue using SDoH EHR screening tools even after study completion.

Benefits

  • The program identified patients with SDoH risk factors and, if they wanted help, connected patients to resources.
  • Providers had greater knowledge of social factors that could increase patients’ health risks.
  • EHR documentation of SDoH data may facilitate care plan adjustments, referral to social services, and tracking results of such referrals.

Unique Challenges

  • EHR-based SDoH data tools in which relevant data appeared in multiple places created a fragmented view of patients.
  • EHR-based SDoH data tools could also add a layer of difficulty to collecting and acting on SDoH data due to lack of staff EHR access and/or expertise.
  • Time to data entry:  The clinics chose paper-based SDoH screening because patients did not complete the form through the online portals and staff found paper forms easier. Not all clinics specified which staff member was responsible for data entry and in what time frame the data was expected to be entered. At Clinic C, data entry had to be done within 48 hours of screening, but this was not specified at other clinics. Delays in data entry prevented properly addressing SDoH needs.
  • Staff utilization of EHR tool: not all staff involved had security access to the EHR tool, and had to obtain subsequent clearance which delayed tool utilization.
  • The EHR SDoH referral tool, utilized only by clinic A, facilitated matching specific needs to referral resources. At Clinics B and C, CHWs completed referrals, and often lacked the information required to match referrals to specific SDoH needs.

Personnel Challenges

  • Staff EHR proficiency required training and time, but was crucial in driving intervention uptake.
  • Staff turnover/need for staff training impeded workflow.
  • Referral workflows were seen as too time-consuming. Because of the high positive screening rates, volume of required follow up was initially insurmountably high. After a question was added to the screening tool asking if patients desired follow-up for SDoH needs, the volume of required follow-up was reduced and workflow became more manageable.

Sources

Annals of Family Medicine 2018, “Adoption of Social Determinants of Health EHR Tools by Community Health Centers.” 16:399-407. https://doi.org/10.1370/afm.2275.

Editors
  • Anabel Starosta, BA
Location

Pacific Northwest

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