Massachusetts League of Community Health Centers CHI Conference May 3, 2017 AGENDA. Overview of PRAPARE

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1 GETTING STARTED IN USING PRAPARE TO ASSESS AND ADDRESS THE SOCIAL DETERMINANTS OF HEALTH Michelle Jester, Research Manager National Association of Community Health Centers This project was made possible with funding from: Lynn Gonzalez, Associate Director of Behavioral Health Open Door Family Medical Centers Massachusetts League of Community Health Centers CHI Conference May 3, National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information in part of whole without written consent from NACHC. 1 AGENDA Topic Timing Overview of PRAPARE Strategizing Implementation: Lessons from Early Adopters Health Center Example: Open Door Family Medical Center Q&A Challenges Activity Q&A 15 mins 10 mins 20 mins 20 mins 15 mins 10 mins 2 1

2 WHAT IS PRAPARE? Protocol for Responding to & Assessing Patients Assets, Risks & Experiences: A national standardized patient risk assessment protocol designed to engage patients in assessing & addressing social determinants of health (SDH). PRAPARE = SDH screening tool + implementation/action process Customizable Implementation and Action Approach At the Patient and Population Level Assess Needs Respond to Needs 3 PRAPARE WAS DESIGNED TO LEAD TO SYSTEMIC CHANGE Individual level Organizational level System/ Community level Patient and Family Care Team Members Health Center Community/Local Health System Empowered to improve health and wellbeing Better manage patient and population needs Design care teams and services to deliver patient/community-centered care Integrate care through cross-sector partnerships, develop community-level redesign strategy for prevention, and advocate to change local policies Payer level Policy level Payment State and National Policies Execute payment models that sustain valuebased care (incentivize the social risk interventions and partnerships, risk adjustment) Ensure capacity for serving complex patients, including uninsured patients 4 2

3 TIMELINE OF THE PROJECT Year Year Year Develop PRAPARE tool Pilot PRAPARE implementation in EHR and explore data utility PRAPARE Implementation & Action Toolkit Dissemination 5 DEVELOPING PRAPARE Aligned with National Initiatives: * Healthy People 2020 * ICD-10 * Meaningful Use Stage 3 * NQF on Risk Adjustment Experience of Existing Protocols Burden of Data Collection Criteria Actionability Sensitivity Stakeholder Feedback Literature Review Identified 16 Core Social Determinants of Health 6 3

4 PRAPARE DOMAINS UDS SDH Domains Core Non-UDS SDH Domains (MU-3) 1. Race 10. Education 2. Ethnicity 11. Employment 3. Veteran Status 12. Material Security 4. Farmworker Status 13. Social Isolation 5. English Proficiency 14. Stress 6. Income 15. Transportation 7. Insurance 16. Housing Stability 8. Neighborhood 9. Housing Status 1. Incarceration History Optional 3. Domestic Violence 2. Safety 4. Refugee Status Spanish and Chinese (Mandarin) translated versions Find the tool at: 7 PRAPARE EHR TEMPLATES Currently available: NextGen eclinicalworks GE Centricity Epic Available for free after signing EULA at In development: Greenway Success EHS (summer 2017) Greenway Intergy Allscripts (late 2017) Meditab (late 2017) Athena Cerner 8 4

5 EHR TEMPLATE FUNCTIONALITIES EHR Builds: NextGen: Built into base in as stand-alone template. Compatible with latest KBM. Tablets/Kiosks Build available from Otech at $1,500 per configuration or with NextGen NextPen Reporting Tools from OSIS ecw: Smart Form available for $1,000 per database. Centricity: Custom Template & Vendor Template that maps PMS to EHR Epic: OCHIN Epic and Epic PRAPARE Data maps to existing data in EHR and PMS (except ecw) Some templates match to ICD-10 Z codes and added to problem list EHR templates have reporting capabilities and tools to extract, export, and aggregate data NextGen Reporting Tool ecw: structured data, BridgIT 9 Courtesy of Siouxland Community Health Center & AllianceChicago 5

6 WHAT MAKES PRAPARE UNIQUE AND FEASIBLE? 16 core domains that have been standardized All align with national initiatives (HP2020, UDS, IOM, MU, NQF, etc) Design Vetted and stakeholder engaged development process In the EHR to facilitate assessment & interventions (free templates) Conversation starter and patient-centered Common core yet flexible: Able to make more granular and/or add questions Focus on standardizing the need, not question Can be used in combination with other tools/data 11 PRAPARE IS A NATIONAL MOVEMENT! Health Centers in 44 states are already using PRAPARE EHR templates Interest from CHCs in every state Most PCAs and HCCNs Some hospitals and health systems 12 6

7 What We Learned 13 PILOT RESULTS Easy to administer Builds patient-provider relationship Identifies new needs Many patients face between 4 7 social determinants of health Positive correlation between number of social determinants and likelihood of having hypertension 14 7

8 HOW PRAPARE DATA HAS BEEN USED TO IMPROVE CARE DELIVERY AND HEALTH OUTCOMES INDIVIDUAL Level Build new or expand existing services inhouse for same-day use as clinic visit (children s book corner, food banks, clothing closets, wellness center, transportation shuttle, etc) Ensure prescriptions and treatment plan match patient s socioeconomic situation (all) POPULATION Level Build partnerships with local organizations (ex: Iowa and NY transportation) Create risk score to identify complex patients (ex: Hawaii, NY, OR) Guide work of local foundations (ex: New York housing) Streamline care management plans for better resource allocation (ex: Hawaii) System and Policy Level Inform health delivery redesign (ex: Medicaid and Medicare ACO discussions in Iowa, New York) Use data for seat at the table with payers to discuss sustainable payment and APM (all) 15 PRAPARE IMPLEMENTATION & ACTION TOOLKIT Chapter 1: Understand the PRAPARE Project Chapter 2: Engage Key Stakeholders Chapter 3: Strategize the Implementation Process Chapter 4: Technical Implementation with EHR Templates Chapter 5: Develop W orkflow Models Chapter 6: Develop a Data Strategy Chapter 7: Understand and Evaluate Your Data Chapter 8: Build Capacity to Respond to SDH Data Chapter 9: Respond to SDH Data with Interventions Chapter 10: Track Enabling Services 16 8

9 Getting Started: Deep Dive into Implementation RIGHTS/CDS PILOT SITE EXAMPLE 1) Right information: Review PRAPARE questions and response choices Which ones are already collected/documented? 18 9

10 5 RIGHTS/CDS EXAMPLE IN DETERMINING IMPLEMENTATION OF PRAPARE TOOL 2) Right people- who Who will collect it? Who will need to see it to inform care? Who will respond to needs identified? 3) Right channels- where Where are we collecting this information? Where do we need to display and share this information (team huddles, etc.)? 4) Right format- modality How are we collecting the information and in what manner are we collecting it? 5) Right time- When? Collecting it at the right time in staff and patients workflow 19 SAMPLE DATA COLLECTION WORKFLOWS Health Center CHC #1 CHCs #2 Who Where When How Rationale Non-clinical staff (enrollment assistance, community health workers) Nursing staff and/or MAs In waiting room Before provider visit Administered PRAPARE with patients who would be waiting 30+ mins for provider In exam room Before provider enters exam room Administered it after vitals and reason for visit. Provider reviews PRAPARE data and refers to case manager Provided enough time to discuss SDH needs Wanted trained staff to collect sensitive information. Waiting area not private enough to collect sensitive info CHC #3 Non-clinical staff (patient navigators, patient advocates) In patient advocate s office After clinical visit when provider refers patient to patient navigator Patient advocates administer it and then can relay to provider in office next door. Wanted same person to ask question and address need. Often administer PRAPARE with other data collection effort (Patient Activation Measure) to assess patent s ability and motivation to respond to their situation. CHC #4 Care Coordinators In office of care coordinator When Completing chart reviews and administering Health Risk Assessments Administered PRAPARE in conjunction with Health Risk Assessments Allows care coordinators to address similar issues in real time that may arise from both PRAPARE and HRA CHC #5 Any staff (from Front Desk Staff to Providers) No wrong door approach No wrong door approach Allows everyone to be part of larger process of painting a fuller picture of the patient and taking part in helping the patient 10

11 PLANNING FOR RESPONSES TO NEEDS IDENTIFIED 21 USING 5 RIGHTS/CDS TO PLAN FOR RESPONSES 5 Rights Responses/Interventions What/Information Comprehensive list of resources & referral list for needs Who How/Format Where/Channels When/Workflow Given to patient by person administering the PRAPARE questionnaire. [Note: AmeriCorps staff to keep resource list up to date] Searchable database of resources; Printed resources in 3-ring binder On employees intranet; placed in provider s hallway, front desk Resources will be given immediately to patient once need is identified; referral to appropriate staff will be made after patient sees provider 22 11

12 BUILDING CAPACITY TO RESPOND 23 IN HOUSE OR PARTNERSHIPS? 24 12

13 HEALTH CENTER EXAMPLE: OPEN DOOR FAMILY MEDICAL CENTER 25 PRAPARE Implementation -Open Door Family Medical Centers Objectives: Open Door Family Medical Centers History Patient Population Why PRAPARE? Data Gathered Next Steps 13

14 Open Door Family Medical Centers Founded in the basement of a church in 1972 Originally staffed by volunteer Doctors and Nurses Gained Federally-Qualified Health Center recognition and Section 330 funding External Accreditation Joint Commission & NCQA JCAHO since 1998 Keen focus on patient safety, staff competency, led to enhanced Quality Improvement capabilities NCQA PCMH Level 3 since 2009 Importance of patient access and primary care provider empanelment; focus on transitions of care and care coordination DRP NCQA Recognition since 2012 Evidence-based care of patients with diabetes emphasized 14

15 Open Door Services Licensed under Department of Health Article 28 6 Primary Care Sites in Two Counties 7 School-based Health Centers Mobile Dental Vans Family Medicine Residency program Dental Residency program Open Door Family Medical Centers At the end of 2016, we had: Over 100 Medical, Behavioral Health, and Dental clinicians providing care to 50,000+ patients in 280,000+ visits 15

16 Target Population Low income (200% or Below Poverty Level) Note: According to the new 2016 Federal Poverty Guidelines, income of $24,300/household of 4 is considered at 100% poverty level. Uninsured Underserved High Risk Population Women of Child Bearing Age Families and Children Income as a Percent of Poverty Level About 87% of Open Door patients fall into 200% or below poverty level. 2% 5% 11% 16% Income of $36,450 household of 4 66% Income of $24,300/ household of 4 100% and Below % % Over 200% Unknown Note: According to the 2016 Federal Poverty Guidelines, income of $24,300/household of 4 is considered at 100% poverty level 16

17 Principal Third Party Medical Insurance Source Open Door Patients in % 13% 5% Uninsured 43% Medicaid CHIP Medicare 39% 35% Private Why Now? We have evolved from saying non-compliant to non-adherent We need to evolve from saying non-adherent, to what may I be missing about my patient? To take better care of our toughest medical patients, often the key is to uncover and address the underlying BH and social determinants of health issues. 17

18 Addressing the Gap Consultation model for psychosocial issues on the medical units Behavioral Health Integration Specialist (BHIS) Licensed Clinician (LMSW) Embedded, full-time member of the primary care team BHIS patient interactions are not billed (not reimbursable) 18

19 Pilot to Purpose: Initial Foray into Gathering SDH Screening for needs Assessing patients Holistically & Ecologically Gathering Social History Pilot Project in PRAPARE questions embedded in the EMR (Social History) PRAPARE entered into EHR as a SMART form in January, 2017 Who is Doing PRAPARE? Behavioral Health Integration Specialist (BHIS) Clinicians Embedded in the medical units LMSW- Licensed Masters Social Worker Perform BH assessments and link patients to BH care Meet with patients in exam rooms before or after provider enters BHIS screens patient because of a previously documented unmet health concern, previous BH involvement, or new patient to Open Door Provider identifies a BH concern and calls in BHIS 19

20 Patient Advocates Staff Bachelor level support In proximity to medical units Access (identify needs, health insurance, Wellness program) Health literacy (Chronic Disease Management Education) Medication compliance (Pharmacy Assistance Programs, review visit summaries, etc.) Treatment/appointment adherence PRAPARE DATA 3,750 surveys done from 7/1/15 present 60% done by Behavioral Health Integration Specialists (BHIS) 30% done by Patient Advocates 10% clinical providers 69% born outside of U.S. 76% of respondents speak Spanish as primary language 27% of respondents say they are quite a bit, somewhat, or very much stressed 39% have less than a high school degree 19% reported going without food, clothing, utilities, childcare, medicine/medical care when it was really needed 20

21 Challenges Questionnaire can become a lengthy conversation- this takes time Engagement is Key for eliciting robust responses Staffing Shortages Lack of Resources for the uninsured population Tracking Referrals/Follow-up Next Steps Evaluate data Establish strong ties to CBO s Establish culturally sensitive practices based on PRAPARE data Spanish version of PRAPARE Establish screening goals 21

22 Thank You! Lynn Gonzalez, LCSW Associate Director of Behavioral Health (914) QUESTIONS AND DISCUSSION For more information, visit To receive the latest updates on PRAPARE, join our listserv! Michelle Jester at 44 22

23 GETTING STARTED 45 STATE MODELS FOR IMPLEMENTING PRAPARE Medicaid (2703 Health Homes, etc.) Private Foundation Grants Cooperative Agreement Aligning with other state initiatives (payment reform, delivery system transformation, quality, etc.) Just doing it! 46 23

24 Starting Small: Experimenting with PRAPARE in Oregon APCM Clinics We invited clinics to pick a patient population and interview 10 consumers using 3 questions from PRAPARE Afterwards, clinics met face-to-face to share their experiences How did you and the patient discuss these questions? What did you observe about the process (your experience, patient s reaction)? Did asking these questions lead to conversations about other topics? 47 RESOURCES AVAILABLE NOW Visit PRAPARE Tool PRAPARE Implementation and Action Toolkit Electronic Health Record PRAPARE Templates Readiness Assessment Webinars PRAPARE Overview EHR and Workflow-specific Frequently Asked Questions Contact: Michelle Jester at mjester@nachc.org Visit AAPCHO s Enabling Services Accountability Project protocol for data collection of non-clinical enabling services Enabling Services Data Collection Implementation Guide and Best Practices Contact Tuyen Tran at ttran@aapcho.org Upcoming Opportunities: * Train the Trainer Academy * CHC Engagement Grants * Resources from State Pilots 48 24

25 CHALLENGES ACTIVITY 49 Challenges and Overcoming Challenges Think about what challenges you anticipate facing as you implement PRAPARE Volunteers will present their challenges to the group We ll use the collective brainpower of the group to troubleshoot these challenges 50 25

26 QUESTIONS AND DISCUSSION For more information, visit To receive the latest updates on PRAPARE, join our listserv! Michelle Jester at 51 Aspects to Consider When Strategizing Implementation Plans What other activities could PRAPARE leverage and/or add value to? Does this affect or inform the workflow model? What will the population of focus be? How does that affect the workflow model? Who will be involved in the implementation of PRAPARE? Data collection, input data, exporting data, responding to needs identified Where and when will data be collected and needs responded to? What modality will be used to collect PRAPARE data and respond to needs identified? In-person with staff or self-assessment through tablets, kiosks, patient-portal, paper, etc. What resources are available to respond to needs identified? Develop plans and process for using the data for enhanced clinical care, complexity analyses, and advocacy for more effective payment