Overview

This project sought to integrate a cost-effective social needs assessment into Northeast Ohio Medical University’s SOAR Free Clinic.

Organization Type

• Free clinic

National/Policy Context

Because most people using free clinic services tend to be of lower socioeconomic status, they are more likely in need of assistance in other aspects of health access as well, including transport, childcare, and/or food needs.^1,2  Those living below the poverty line are more likely to be of lower health status, have chronic illness, and premature death than those living above the poverty line.² An assessment of patients’ social determinants of health is essential to providing comprehensive medical treatment. A lack of consideration for social determinants can lead to an increase in health inequity and inequality.² Clinics across the nation have made efforts to integrate social needs into care provided to their patients.

A study conducted in 2016 estimated that more than 95% of the money spent on healthcare in the U.S. was for direct medical services, despite the fact that 60% of preventable deaths were caused by modifiable behaviors and exposures in the community.⁴ In the long term, accounting for social determinants will lead to a healthier population and provision of health care that accounts for social determinants will reduce the amount of people needing medical care overall.³

Local/Organizational Context

Since its inception in September of 2016, NEOMED’s SOAR Free Clinic has seen and helped over 100 unique patients. In March of 2018, the clinic determined that next step in providing healthcare would be to address the social needs of its patients. By May of 2018, the project had been planned and approved by the IRB. It was then conducted on on June 2, June 16, and July 7, 2018. On each clinic date, a slightly different plan was used, to find the most efficient outcome (as shown below in process flow charts).

Resources available to address social needs vary geographically.² As per Portage County’s 2016 County Community Health Status Assessment, statistics showed that those who earn less tend to have poorer attitudes towards health and poorer health outcomes.

NEOMED is located in a rural area, where there is limited access to resources. The SOAR Free Clinic is the only true free clinic in the area, as all other free clinics in the area operate on a sliding scale model. Additionally, the few asset inventories in existence for the area were no longer functioning or identified resources too far away for use. Further, because Portage County is so rural, it was difficult to set up projects to address social determinants of health.

Patient Population Served and Payor Information

The population served includes patients using the services of NEOMED’s SOAR Free Clinic. The overall demographic is the low-income population of the Northeast Ohio area – namely Portage County and surrounding areas. The clinic is free-of-charge. It is sponsored by Summa Health of the Akron area and is run by NEOMED’s medical and pharmacy student volunteers as well as a clinic chief and attending physicians.

Funding

Necessary supplies were provided by NEOMED’s Public Health Department.

Research + Planning

This project was approved by NEOMED’s Public Health Department, NEOMED’s IRB team, and Youngstown State University’s IRB team. The project itself consisted of:

1. Employing a social needs survey on three different clinic dates (6/2/18, 6/16/18, 7/7/18)
2. Recording patient flow through the clinic, which was done by way of process flow charts (included in original paper and on poster presentation)
   *on each clinic date, the process flow chart was changed based on observations from prior clinic dates and from various literature reviews
3. Patient data, while not used for this project immediately, was coded and stored for future project use

In order to do this, both a community asset inventory and a social needs assessment was created. The community asset inventory, while not based on a particular model, was created as a combination of preexisting asset inventories as well as other resources. All resources were checked for individual resources provided and availability before being included. The social needs assessment was modeled on the Health Leads social needs assessment, which has already been created and tested for ease-of-use. Before implementation of the project, a literature review was conducted on the significance of social needs assessments and successful integration of new systems in existing process flow through clinics. Due to a specific lack of literature on rural clinics, there was no scaffold provided for the project in particular. The Plan-Do-Study-Act (PDSA) Model was used to conduct the quality improvement project. As the project was being implemented, on a weekly basis, patient data was taken and gathered, and process flow charts were created. Weekly changes were made to the project to improve survey implementation.

Tools or Products Developed

An updated community asset inventory was made, as well as a social needs assessment for patients to complete. Process flow charts were created, and data was converted into graphs using Microsoft Word. Excel was used to track patient responses.

Training

Medical students who helped implement the survey were trained in survey administration and providing patients resources to address their social needs appropriately. They were also trained in recording and coding data. Training happened before clinic days began, and took 30 minutes to explain social determinants, the survey, and use of the community asset inventory, and how to appropriately address patient needs. Akanksha Dadlani ran the training, and used a short PowerPoint presentation. The training concluded with medical students practicing addressing social needs with one another.

Tech Involved

• Google Maps
• Microsoft Office
• Statistical software

Workflow Steps

• On clinic dates, the project consisted of training the education team for the day on the project and debriefing them on how many patients we were expecting.
• The surveys were then administered by a public health student or a medical student on the education team, and patient start-to-finish times at the clinic were recorded.
• The surveys were then collected, and patients were given appropriate resources to address their social needs.
• After the clinic day was over, patient times were recorded and data was appropriately coded.
• The administration of surveys varied every cycle in order to measure the most effective method of implementation.
• The process flow charts included below explain the differences in each cycle.

Budget Details

Printing the surveys and supplemental materials for patients, which was supplied by NEOMED’s Public Health Department.

Where We Are

Continuing; the project is being permanently implemented into the clinic as part of the Quality Improvement and Education teams.

Outcomes

The primary recorded outcome of the project was:

Average time patients spend at the clinic: the average patient time for the three clinic days with the social needs assessment was compared to average patient time without the social needs assessment. The ultimate goal of the project was to implement the social needs assessment without increasing the average amount of time patients spent at the clinic. The goal was ultimately achieved.

Table 1: Collected Data of Patient Start-to-Finish Time

Cycle Number	Time Spent in Clinic (in minutes)	2018 Baseline Data
1	97 minutes	117 minutes
2	86 minutes	117 minutes
3 (Adapted)	108 minutes	117 minutes
Average	97 minutes	117 minutes

Graph 1: Collected Data of Patient Start-to-Finish Time (Adapted)

*Baseline data = average patient time spent at clinic without social needs assessment

Time Spent in Clinic = average patient time spent at clinic with social needs assessment

Future Outcomes

• Patient needs are being tracked long-term and checked in on. The education team addresses social needs upon every patient visit and patients are being given resources from the community asset inventory. A goal of the project is to have a permanent public health official present at all clinic dates for patient needs. While the initial project did not include tracking whether or not patients used the resources, one of the long-term goals is to do so and adapt provision of social needs resources appropriately.
• Another consideration being had is converting the community asset inventory to a GIS Google Map so that people can find resources available near their homes or workplaces.

Benefits

• The project indicated that social needs could be a long-term consideration for patients.
• Because of its success, the project has been permanently implemented into the clinic and patient social needs are being tracked and appropriately addressed.

Unique Challenges

• The biggest challenge in setting up the project was a lack of literature on free clinics in rural areas. Because of this, setting up the project was difficult.
• Another challenge was addressing patient needs given the time constraint.

Glossary

Week 1 Process Flow Chart:

The first process flow chart was from the 6/2/18 cycle. Because there was not much literature to back one specific format, the process flow chart was put together based on recommendations by volunteers who ran the clinic who already knew patient flow through the clinic. While parts of this format worked well, other parts needed improvement. The first part that worked well was administering the patient survey right at intake. Because the survey is easy-to-follow, it was generally completed in less than five minutes. The two parts of the existing flow that needed correction were when the form was collected and when the bags containing social needs information were given to the patients.
The average patient start-to-finish time spent at the clinic for this cycle was 97 minutes.

Week 2 Process Flow Chart:

The second process flow chart was from the 6/16/18 cycle. After gaining better understanding of how the clinic flowed, a few revisions were made. The first change is that the form was collected before the patient was taken back. Because the form was so easy to fill out, patients had it completed well before they were checked in. Rather than adding a step and trying to track a patient down halfway through the visit to collect the form, collecting the form early on eliminated that scrambling process, and gave us more time to put together information for the patient. The second issue was at what point to give the bag. In the first cycle, we had a lot of trouble tracking the patient down at the end of their visit because some patients had to go to lab, while others spent extra time with the attending physician. To avoid trying to follow patients, we let them come to us. At the end of every patient visit, the patient comes to the checkout desk. At that time, we gave them their personalized bags.

While we were happy with the cycle changes at this time, there was another consideration that had to be made:

• One patient marked, “No” for all answers on the survey, but later requested the doctor for some help with legal issues and patient advocacy, which was a question on the survey.
• Another patient marked, “No” for all on answers on the survey, but had come in with a history of drug abuse and a chief complaint involving management of drug abuse.

 

Week 3 Process Flow Chart:

The last process flow chart was from the 7/7/18 cycle.
There were not many changes made by way of process flow. The only addition was that the form was better explained to the patient before administering it. Physicians were also requested to bring up the social needs assessment during their visit to address other concerns that the patient may have had. While this clinic date took the most time, patient surveys matched their medical histories and concerns better.
The average patient start-to-finish time spent at the clinic for this cycle was 108 minutes.

Sources

1. Simpkins B. Free Clinic to Expand Health Services From Hopkins To Uninsured of East Baltimore Johns Hopkins Medicine Health Library. https://www.hopkinsmedicine.org/Press_releases/2004/10_29_04.html. Published June 17, 2008. Accessed July 17, 2018.
2. Loignon C, Hudon C, Goulet É, et al. Perceived barriers to healthcare for persons living in poverty in Quebec, Canada: the EQUIhealThY project. International Journal for Equity in Health. 2015;14(1):4. doi:10.1186/s12939-015-0135-5.
3. Alley D, Asomugha C, Conway P, Sanghavi D. Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid. New England Journal of Medicine. January 2016:8-11. doi:http://hbex.coveredca.com/stakeholders/plan-management/PDFs/CMS-Accountable-Communities-NEJM-2016-January.pdf.
4. Portage County Community Health Partners. Portage County Community Health Status Assessment. 2016 Portage County Community Health Status Assessment Report. March 2016:1-183. http://www.kentpublichealth.org/Portage FINAL Health Assessment with Cover 3-3-16.pdf. Accessed July 18, 2018.