Overview

Intermountain Healthcare created a Social Determinants of Health Committee in order to devise a strategic plan with which to address social determinants of health for its patients, members, caregivers and community through screening, brief interventions, and referrals to community resources.

Organization Name

Intermountain Healthcare

Organization Type

• Community hospital
• Community organization
• Community outpatient clinic
• Integrated healthcare system/network

National/Policy Context

Intermountain Healthcare is a non-profit integrated healthcare delivery system based in Salt Lake City, Utah comprised of 22 hospitals and approximately 195 clinics throughout Utah and Idaho. Intermountain Healthcare provides health insurance plans from SelectHealth.

• 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 is a big contributor to poor health outcomes, and there are widespread unmet social needs across the members of the community.
• While the aforementioned SDoH are the main focus, the intervention also tries to address secondary SDoH such as health behaviors, access to care, behavioral health and substance use disorder.
• Implementation of the intervention has begun on a smaller scale, with plans to implement it across the continuum of care, including in hospitals, ambulatory care clinics and homecare, and for members of the insurance company, in the next few years.
• Underserved/uninsured community members are also included through community health screening events hosted around the state in locations such as churches, schools and parking lots.
• Initially, this intervention will be focused on Intermountain’s patients, and will eventually be extended to Intermountain’s own employees through employee health screening.

Local/Organizational Context

• Intermountain Healthcare is the largest health system in the state and largest private employer in Utah. Clinics are part of Intermountain Healthcare’s larger network.
• The Social Determinants of Health Committee is a central committee, founded in 2017, which devised the details and plan for the intervention, and is responsible for communicating with clinic administrators and training physicians to implement the intervention.
• Members of the committee included MDs, PhDs in Public Health, Audiology, MPH, RDs, LCSW, communication professionals, and JDs.

Patient Population Served and Payor Information

• Main payor source is SelectHealth, Intermountain Healthcare’s insurance plan.
• The SDoH Committee intervention predominantly serves Medicaid patients, specifically through SelectHealth Community Care which is SelectHealth’s Medicaid plan, and uninsured community members.
• Once intervention roles out in clinic, all patients, regardless of payor source, will be screened and referred to appropriate services.

Leadership

• SDoH Committee was co-chaired by Elizabeth Craig, who works for SelectHealth, and Dr. Elizabeth Joy.
• The committee was organized into five subcommittees, which were each responsible for devising plans for one of the following:
  1. Screening people for SDoH
  2. Brief interventions and internal referrals for community resources
  3. Developing strategies within organization and across the community
  4. Communication and Public Policy
  5. Evaluation and Research

Research + Planning

• SDoH Committee sub-committees began meeting in 2017 and met on a monthly basis, and in December 2017, delivered a strategic plan to Intermountain Healthcare senior leadership.
• Committee considered questions such as ‘where are the gaps?’ and ‘what are we trying to solve?’ in defining what needed to be included in the strategic plan.
• Strategic plan outlined background information about SDoH, the purpose of the intervention, the SDoH needs assessment surve, and the following two strategies for improving health outcomes:
  1. The first strategy involves brief interventions and navigation to services, such as 211 referrals and streamlining the process of helping patients utilize community services.
  2. The second strategy involves internal and community partnerships to ensure that patients who are referred to services post-SDoH screening are able to access appropriate resources.
• In 2018, the Committee operationalized the strategic plan and set implementation goals. Because the Intermountain system is so large, the SDoH Committee recognized that it would be unfeasible to implement this intervention across its whole network at once,  and first focused on community health screenings for underserved and uninsured patients.
• Community partnerships, such as with food banks, meals on wheels services, and affordable long-term housing, were established in order to for referrals to be effective in providing resources to patients.
• Gap analyses were conducted to see what kinds of community resources were still missing and what barriers to accessing available resources existed to maximize intervention’s benefit.

Tools or Products Developed

• Social Check Questionnaire: Intermountain created a one-question needs assessment survey known as Social Check, which is used to assess social determinants of health in a clinical setting. Social Check was derived from the material security question found in the National Association of Community Health Center’s Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE).[1]
• The Social Check questionnaire is as follows:
  1. Life is not always easy. We want everyone to have a safe and healthy environment so we’re asking everyone about challenges they face. If there’s a problem we may be able to help.  Today or in the past year have you or someone in your household had to go without any of the following when it was really needed:
     • Food
     • Rent or mortgage payment
     • Utilities
     • Feeling safe at home
     • Transportation
     • Educational resources
     • Dental care
     • Medicine or prescriptions
     • Medical services such as a doctor or hospital
     • Mental health services
     • Substance use disorder services
     • Other

• Screening positively in these categories dictates which resources patients are then referred to.

[1] The PRAPARE social determinants of health assessment protocol was developed and is owned by the National Association of Community Health Centers, in partnership with the Association of Asian Pacific Community Health Organization, the Oregon Primary Care Association, and the Institute for Alternative Futures.  For more information about PRAPARE, visit www.nachc.org/prapare.”

Training

• Training about SDoH consisting of required conferences for PCPs called “clinical learning days.” SDoH care process models are presented and distributed at these conferences.
  1. Care process models are tools used to educate clinicians and care teams about a particular topic. In this case, the model provided background about why SDoH is important, discussed who would be responsible for what, what the intervention’s tools were, and what the process of the screening and referral would be.
• Newsletters and online distribution systems detailing changes were also used to train MDs.
• Clinical administrators were specifically contacted to ensure that the physicians they oversee attended these conferences and to enforce the incorporation of these care process models into practice.
• Care managers and care guides receive similar training to physicians, focusing on communication strategies, although the structure of their training is less specifically defined.

Tech Involved

• Cerner
• Electronic medical record
• Paper & pen

Team Members Involved

• Case Management
• Community Health Worker
• Health Coach
• MAs
• Pharmacist
• Physicians
• RNs
• Social Worker

Workflow Steps

• Screenings:
  • In the community:
    • Screenings are set up in public locations in the form of many booths. These booths screen for potential health problems such as hypertension, depression, health behaviors and SDoH.
    • Health screenings are run by health coaches from SelectHealth.
    • Patients do not need to have insurance, and receive a “passport” at the beginning of the event. They take this passport with them from booth to booth, in which the results of each station are recorded.
    • Each booth is dedicated to a certain type of screening, i.e. one focuses on Social Check, a second on behavior health, and a third on diet and exercise.
    • At the end of the screening booths, a health coach reviews their passport results with them and makes recommendations.
  • In clinical settings:
    • Screenings are focused on SDoH and community resources, since other traditional health screenings included in a community screening, such as for hypertension, are included in a medical visit.
    • Screenings are run by care managers, who are mostly RNs but also include social workers and pharmacists.  Care guides, who are MAs trained to take on an expanded role, perform much of the SDoH intervention and report to care managers. Ratio of staff is 2-3 care guides reporting to 1 care manager.
• Brief interventions and referrals: After identifying unmet social needs, “brief interventions” are made, which are quick connections to community resources, such as helping people use 211 or giving them fact sheets about health behaviors.
  • 211: Most patients, regardless of income and insurance status, have smartphones. Using a QR code, Intermountain staff helps patients download app and teach them to use it so they can access community resources.

 

Budget Details

• Hired 2 CHWs to implement SDoH screenings, but exact FTE unknown.
• Intermountain Healthcare created a collaboration called the Utah Alliance for the Determinants of Health which has a budget for SDoH interventions, but this budget has not been used for interventions through the SDoH Committee.

Where We Are

• Intervention began in August 2017, and it is ongoing as of September 2018.
• The SDoH Committee and subcommittees no longer meet monthly, but sub-committee meetings have continued to meet as needed.
• As of now, SDoH screening and referral has been extended to patients and SelectHealth insurance members, but not yet to Intermountain Healthcare employees.
• In late 2018, Intermountain will begin implementing screenings in homecare program.
• In 2019, Intermountain will begin implementing screenings across primary care clinics and emergency departments.

Outcomes

• This intervention is currently in the implementation stage, so specific outcomes have not yet been measured. However, they key outcomes are:
  • Reach: a quantitative measure of how many people who meet eligibility criteria for screening are actually screened and directed to appropriate resources.
  • Effectiveness: measured at both the organizational and individual level in terms of health outcomes, person experience, cost and care provider burden. For example, over an 18 month period, was there a decline in non-emergent emergency department visits/claims?
  • Adoption: a quantitative measure of how many Intermountain Caregivers/teams are implementing the intervention.
  • Implementation: a qualitative measure, such as through focus groups, to identify if Intermountain Caregivers/teams can implement the intervention with fidelity.
  • Maintenance: As time progresses, will analyze if SDoH interventions are sustainable over time.

Future Outcomes

• Does screening, brief intervention, referral and navigation to services for SDoH:
  • Reduce ED use?
  • Reduce total cost of care?
  • Impact patient experience and satisfaction with care?
  • Impact caregiver experience?
  • Impact relationships with community partners?

Benefits

• Benefits of the intervention itself are still unknown, but the main benefit of the implementation phase thus far is raising awareness of the importance of screening for and addressing unmet social needs of patients.

Unique Challenges

• Implementing this intervention across a very large healthcare system that provides care in different settings requires implementing in one group at a time and making adjustments, i.e. in terms of personnel doing the screenings, based on the healthcare setting.

Personnel Challenges

• Uptake of the intervention still unknown due to relatively recent implementation.