Kings Fund Masterclass A Session 2: Care Communities Development and Social Determinants of Health (SDOH)

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1 Kings Fund Masterclass A Session 2: Care Communities Development and Social Determinants of Health (SDOH) 1

2 Objectives Provide overview of clinical and community-based network development process Discuss key underlying drivers of healthcare costs Develop understanding of role that social determinants of health (SDOH) play in person s healthcare Describe Montefiore s experience and approach to managing needs of whole person leveraging data Discuss specific interventions being deployed by MHS to improve the health and well-being of our communities (Video) 2

3 Clinical and community-based network development Hudson Valley region expansion Used geo-analytics to identify networks gaps aligned with needs of our targeted population Mapped provider locations against location of our attributed population Compared target projections and current allocated supply to identify network gaps 3

4 Clinical and Community provider networks constantly evolving to meet population needs Primary Care MD Legal Aid Integrated Child Behavioral Welfare Health Employment Specialist Assistance MD Enabling Coordinated Care Transportation Pharmacy Analyzing patient Relationship population Post, Sub- to identify Education Acute network Care gaps Community- Clinical Based Delivery Organizations CMO Network (CBOs) Financial Ancillaries Services Urgent Care Housing / ED Healthy Hospital Food Options 4

5 Example Initiatives to Support Vulnerable Populations Community-Based Organizations (CBOs) Clinical Delivery Network Employment Assistance Transportation Specialist MD Pharmacy Legal Aid Community- Based Organizations (CBOs) Housing Primary Care MD Clinical Delivery Network Urgent Care / ED Child Welfare Healthy Food Options Integrated Behavioral Health Hospital Relationship Education Financial Services Post, Sub- Acute Care Ancillaries Housing at Risk Real Time flagging of individuals who present in the ED or are admitted to the hospital Healthy Food Options Working with community bodegas to increase supply, improve promotion, drive demand for fresh fruits/produce, water/low-cal beverages, healthy snack options Primary Care Resources Enhanced staffing and systems to address patients mix of medical and psychosocial issues Integrated Behavioral Health Evidence-based model for treatment of depression and/or alcohol abuse with chronic medical conditions 5

6 Hotspotting Social Determinants of Health: Obesity Rates Rethink Your Drink events have occurred in neighborhoods with high rates of obesity 6

7 Hotspotting Food Insecurity Actionable data to drive community partnership development Enables targeted nutrition education and localized engagement of food vendors 7

8 Community Partnerships Engaging youth groups, schools and local community-based organizations around advocacy for improved food access in their communities Nutrition education and train the trainer programming o Sugary beverage education o Food label reading workshops o Food prep/cooking demos Don t Stress, Eat Fresh joint Marketing Campaign with other Bronx-based bodega projects through Bronx Bodega Partners Workgroup 8

9 Bodega Modifications Small changes can have major impact Fruit at check-out counter Baskets Signage Water at eyelevel 9

10 Creating SDOH bundles to coordinate needs of patients Behavioral Health issues, food insecurity, homeless Diabetic, morbidly obese, chronic heart failure Patient A Employment Assistance Transportation Specialist MD Pharmacy Legal Aid Community- Based Organizations (CBOs) Housing CMO Assess Primary Care MD Clinical Delivery Network Urgent Care / ED Child Welfare Healthy Food Options Integrated Behavioral Health Hospital 10 Relationship Education Financial Services SDOH Care Bundle Post, Sub- Acute Care Ancillaries

11 SDOH Care Bundling Patient A Community- Based Organizations (CBOs) Transportation Housing CMO Specialist Primary MD Care MD Pharmacy Clinical Delivery Network Healthy Food Options Homeless Care PCP provides services at homeless shelters Integrated Behavioral Health Patient flagged for housing issue while in ED CMO coordinates with respite housing org to provide housing post-discharge Housing organization facilitates long-term housing solution 11 ER usage and re-admissions reduced drastically

12 Building Upon A Solid Foundation Upon establishing basic infrastructure, new population subsets will be identified over time Legal Aid Child Welfare Employment Assistance Transportation Community- Based Organizations (CBOs) Substance Abuse Case Management Services: NYC Human Resources Administration (HRA) Housing Healthy Food Options Child Welfare specialized prevention programs: NYC Administration for Children s Services Workforce investment organization (homebound care management training): NY State Medical / Psychiatric Disorders Case Management Services: NYC Human Resources Administration Health Home Care Management Program: NYS Medicaid Care Transitions for the Severely Mentally Ill: Federal CMMI grant Opportunities for new program development and evolution in partnership with city, local, state, federal government Relationship Education Financial Services Health Professions Opportunity: Federal grant Supporting Healthy Relationships Couples Education: Federal grant 12

13 What Matters to You (WMTY) campaign Encapsulates our patient-centered focus Frames our efforts to build meaningful relationships with patients on both clinical and personal levels Allows us to discover a patient s social determinants of health Video briefly discusses integrated behavioral health, coordination with PCPs and broader community of care 13

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