Overview

Collection of patient reported outcome measures (PROMs) to assess for unmet social determinants of health among Medicaid patients and to facilitate completion of a Health Risk Assessment among Medicare patients

Organization Name

Internal Medicine Associates at Massachusetts General Hospital

Organization Type

• Academic Hospital
• Academic Medical Center
• Community outpatient clinic
• Integrated healthcare system/network

Local/Organizational Context

• One of sixteen primary care practices at Massachusetts General Hospital
  • The Internal Medicine Associates (IMA) is further organized into interprofessional healthcare teams called “pods”
• The author, Dr. Blair Fosburgh, serves as the Medical Director of the Internal Medicine Associates.
• All sixteen primary care practices affiliated with Massachusetts General Hospital are rolling out PROM assessment projects.

Patient Population Served and Payor Information

The Massachusetts General Hospital primary care practices serve a diverse patient clientele from a population and payer source perspective.

• About 65% of patients who come to MGH have commercial insurance, 30% have Medicare and 5% are on Medicaid.
• However, there are fewer non-English speaking patients than in other clinics within the Boston area.

Leadership

• Project spearheaded and overseen by Dr. Fosburgh within the IMA practice.
• A large Partners level team developed the tool described below and an internal practice team helped implement it.

Research + Planning

• Prior to project rollout, mapped out existing processes of patient contact to identify appropriate time for patients to fill out PROMs.
• Assigned particular duties to medical staff
  • Administrative Assistants identify if patients should be given a questionnaire at all (i.e. if they are Medicare or Medicaid patients) based on prompts from the EMR. They also hand patients tablets at their visits.
  • Medical Assistants assess for completion of questionnaires during the visit and follow up with patients who screen positive for issues related to social determinants of health.
• Protocols developed for referring patients who screened positively for issues pertaining to social determinants of health to the community organization Health Leads, which can connect patients to community resources. IMA had a pre-existing relationship with Health Leads.

Tools or Products Developed

PROMs Questionnaire Design & IT Navigation

• IT resources external to the practice designed tablet interface for PROM questionnaires that would deliver different questions based on the patient’s payor source.
  • Medicare patients – Questionnaire helps answer questions that are part of Medicare’s Health Risk Assessment for the Annual Wellness Visit.
  • Medicaid patients – Questionnaire screens patients for issues pertaining to social determinants of health, including housing, education, transportation, food, finances, dependent care, employment, and utilities needs.

Training

• Staff members involved were trained during an in-person meeting led by Dr. Fosburgh to inform them of the implementation process and re-trained as needed to fulfill their new duties.
• This training was held on a pod-by-pod basis until all staff members involved with the different pods were trained.

Tech Involved

• Epic
• iPad

Team Members Involved

• Administrative Assistant
• MAs
• Physicians

Workflow Steps

• When eligible patients are scheduled for an annual physical exam appointment, they are automatically assigned the appropriate questionnaire.
• Patients are handed a tablet upon their arrival to an appointment. They complete the tablet-based questionnaires before the medical assistant enters their exam room.
  • If the patient does not complete the questionnaire in this time, the MA will assist the patient with completing the questionnaire.
• If the patient screens positive, information related to the area they need help with is automatically added to the after visit summary, and medical assistants are asked to “tee up” a referral to Health Leads.
• The physician reviews and discusses the completed questionnaire responses and, if indicated, signs the Health Leads referral.

Budget

• $10K to $25K

Budget Details

• The intervention was budgeted for and paid for centrally by MGH, with exact costs not made known to the practice.
• Overall, ten iPads and ten iPad storage units had to be purchased for the intervention. The primary care practice itself only had to pay for the storage units.
• A 10.5 inch IPad pro costs about $930 so ten of these would cost $9,300.
• We estimate the intervention thus cost the practice ~$10,000.

Where We Are

The intervention is currently ongoing

Outcomes

• In the three pods in which the questionnaires have been implemented, there has been an increase in screening rates for depression.
  • 47.5% of patients eligible for routine major depressive disorder screening were screened from the beginning of 2017 until November 2017.
  • Two weeks after PRO implementation, this rate had increased to 50.2%.
• Social determinants of health outcomes are pending

Benefits

• This intervention has lessened documentation burdens for the providers involved.
• The tablet-based PROMs questionnaires have allowed the practice to more easily capture and record patient information. This ultimately facilitates the practice acting more quickly on said patient information.
• Patients find the tablet-based questionnaires easier to complete than paper-based questionnaires.

Unique Challenges

• The iPads sometimes malfunction and must be cleaned after each use.
• It is difficult for a provider to read the PROMs questionnaire responses as the information flows into Epic.
• For example, some patients have multiple questionnaire results, making it difficult for providers to read through all responses quickly.
• It is challenging to organize giving the PROMs questionnaire to a patient when the patient arrives late for a visit.