Social Determinants of Health Webinar

Size: px

Start display at page:

Download "Social Determinants of Health Webinar"

Ira Singleton
6 years ago
Views:

1 PART: Preventing Avoidable Readmissions Together Social Determinants of Health Webinar Neal Axon MD Ana Defede PhD Melanie Matney

2 PART: Preventing Avoidable Readmissions Together To provide an overview of the determinants of health shaping the delivery at the patient and provider levels. To highlight components of the determinants required under the Proviso as well as how hospitals can use them for other patient populations To illustrate examples of ways to capture this information with available participating hospital tools. To highlight the required measurement tools under the Proviso. 2

3 Hospital and Clinic Innovations Proviso: DETERMINANTS OF HEALTH WEBINAR Ana Lòpez-DeFede, PhD, Research Professor University of South Carolina Institute for Families in Society Division of Policy and Research on Medicaid and Medicare October 18, 2013 Under contract with the SC DHHS

4 Framing Social Determinants of Health 4

5 SOCIAL CONDITIONS Social Determinants of Health (Social and Economic Factors) Where one is born, lives, learns, works, and plays matters. (Marmot, 2008) Unemployment Stress Early life Social exclusion Work life Social support Food Transport 5

6 6

7 Required Documentation Using Hospital Attestation and Subject to DHHS Review 7

8 Health Risk Assessment Satisfaction and Outcomes Patient Engagement Health History Environmental Scan 8

9 What documentation is required on determinants of health? Hospitals and participating partners must submit examples of tools, intake, screening, or assessment forms that captures determinants of health. The information should be captured in a format that is available for review by the SC DHHS, e.g., clinical records. The information should be gathered in an interactive format with the ability to document comments. The best questions are framed with descriptive response choices and not in a yes or no format. 9

10 I'm an expert on the News Hour and it isn't how I practice journalism. I am not involved in the story. I serve only as a reporter or someone asking questions. I am not the story. Jim Lehrer SAMPLE QUESTIONS DOCUMENTING DETERMINANTS OF HEALTH 10

11 Health Behaviors (30%) Behavior Tobacco use Alcohol Use Unsafe Sex Sample Question(s) In the past year, have you had unprotected sex with an individual not known to you or without the use of a condom? In the past year, have you been treated for a sexually transmitted disease (e.g., gonorrhea; syphilis)? In the past year, have you been diagnosed or treated for HIV/AIDS? Sample Question(s) In the past year, have you used: tobacco products (e.g., cigarettes, pipe, cigar, chew, etc.)? alcohol ( men > 5 drinks a day; women > 4 drinks a day)? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? 11

12 Health Behaviors (continued) Exercise Sample Question(s) In one week, how many days do you walk or engage in other physical activity (such as walking, housework, etc.)? On those days, how many times are you physically active for at least 10 minutes? DIET Sample Question(s) In the past 6 month, how often did the food you bought not last, and you didn t have money to buy more? How many meals do you eat a day? What do you drink with your meals? In the past three months, have you gained or lost more than 10 pounds without trying? What do you typically eat for lunch? What do you eat as a snack? 12

13 Clinical Care (20%) Access to Care Sample Question(s) How often do you have access to a telephone? How often do you have access to transportation? When was your last dental appointment? In the past 12 months, have you seen a doctor for routine care? If yes, where? In the past year, have you had trouble paying for medications, clinic visits and/or supplies? Quality of Care Sample Question(s) Do you get your prescriptions filled? Do any of these things make it hard for you to take good care of your health? Understanding what your provider tells you. Remembering what your provider tells you. Asking questions when you don t understand. Do you receive referrals to specialty care providers? 13

14 Social and Economic Factors (40%) Education Sample Question(s) What is the highest level of school you have completed? How do you learn new information best? (Check All That Apply) Reading it in English Looking at pictures while someone explains it Reading it in Spanish Listening to someone explain new information Reading it in another language Other: Looking at pictures with words Employment Sample Question(s) What is your current source of income? None Part time job Full time job Social security/ga How many months have you been employed in the past year? None Less than 24 months 24 months or more If not employed, would you be interested in working? Yes No 14

15 Social and Economic Factors (continued) Income Sample Question(s) In the past year, have you had trouble paying for medications, clinic visits and/or supplies? What is your current source of income? How do you make money? (Check All That Apply) Work, on the books (earned income) Pension/Retirement Work, off the books (under the table income) Sex Work/Trade Supplemental Security Income (SSI) Drug Trade Social Security Disability Insurance (SSDI/SSA) Recycling/Scrapping SNAP/Food Stamps Panhandling Unemployment Veteran s Administration (VA) Benefits Plasma Center No Income Other: Family & Social Support Sample Question(s) How many people can you count on in times of need? On a scale of 1 to 5, how often does a family member(s) or friend support you with your healthcare needs? Do you have a spouse or partner? Are there any adults, including your spouse/partner, with whom you have regular talks? Where are you living right now? House/Apartment/Room Streets/abandoned home With friend/relative Other: Shelter/boarding home Prefer not to say Are you at risk to lose your housing? How concerned are you that you won t have a place to live sometime in the next 6 months? 15

16 Determinants of Health Tools Health History Health Risk Assessment Intake Interview Environmental Scan Determinants Discharge Care Coordination 16

17 Tools Incorporating Health Determinants 17

18 CARE MANAGEMENT PRE- ENROLLMENT (with Risk Stratification) CARE MANAGEMENT ENROLLMENT INTAKE Providers Care Plan 18

19 SELF-SUFFICIENCY MATRIX An Assessment and Measurement Tool Created Through a Collaborative Partnership of the Human Services Community in Snohomish County Created by The Snohomish County Self-Sufficiency Taskforce Revised August 1,

20 Required Proviso Measurement Tools 20

22 22

23 23

24 Contact Ana Lòpez-DeFede, PhD

25 PART: Preventing Avoidable Readmissions Together Social Factors and Impact on Readmission Risk R. Neal Axon, MD, MSCR October 19, 2013

26 PART: Preventing Avoidable Readmissions Together SES Factors and Readmission Risk What socio-economic factors affect hospital readmission risk? Retrospective cohort study of 1,351 hospitalized Medicare beneficiaries. Living alone (OR = 1.50, 95% confidence interval or CI= ) Unmet functional need (OR=1.48, 95% CI= ) Lacking self-management skills (OR=1.44, 95% CI= ) Limited education (OR = 1.42, 95% CI = ) Arbaje A. The Gerontologist. 2008;48:495.

27 PART: Preventing Avoidable Readmissions Together Insurance and Access to Care Do insurance coverage and access to primary care affect hospital readmission risk? Prospective Cohort Study among 10,946 General Internal Medicine inpatients treated at 6 large medical centers Compared to patients with private insurance Medicare 73% higher Medicaid 52% higher Self Pay 55% higher Access to a regular physician associated with 33% higher readmission risk Hasan O, et al. J Gen Int Med. 2010;25:211.

28 PART: Preventing Avoidable Readmissions Together Income Inequality Do areas with higher income inequality have higher readmission rates? Retrospective cohort study of 555,000 Medicare patients hospitalized for AMI, pneumonia, and HF. 9% higher rates for AMI 7% higher rates for CHF 9% higher fort Pneumonia Lindenaur P, et al. BMJ. 2013;346:1521.

29 Project BOOST TARGET Tool PART: Preventing Avoidable Readmissions Together

30 BOOST Process Assess Risk Factors (How Many 8Ps?) Determine Risk-Specific Intervention s Assign Responsibility and Document Task Completion

31 BOOST TARGET Tool

32 PART: Preventing Avoidable Readmissions Together Multidisciplinary Team Meetings

33 Summary PART: Preventing Avoidable Readmissions Together

UNIVERSAL INTAKE FORM

Agency Name: Funding Identifier: Los Angeles County Area Agency on Aging UNIVERSAL INTAKE FORM Title IIIB Title C1 Title C2 Title IIIE Title IIIE(G) Linkages IDENTIFICATION DEMOGRAPHICS 1a Date: Applicant