Identifying the Need and Role for Social Services Roles within Primary Care Settings for Complex Patients Linda Robb Blenderman, RN, MSc. Sheena Lyons, S.S.W. Kingston
CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure Presenters: Linda Robb Blenderman, RN, MSc Sheena Lyons, SSW We have no commercial or financial support or interests.
Workshop Objectives Share lessons learned about testing the implementation of a Social Services Worker across the primary care models within Kingston Health Link (KHL) Share lessons learned
Kingston Health Link Stakeholders - design a health link system promoting better health and quality of life for complex patients Align with key Ministry and Regional health initiatives i.e. Ontario Poverty Reduction Strategy, Mental Health & Addictions Redesign Key initiative - test the Kingston Community Health Centre (KCHC) Practical Assistant model for addressing social determinants across 9 primary care organizations
Kingston Health Link System CRISIS Social When the scales of health are tipped there is an imbalance between health domains Physical Patient Mental Adopt unhealthy coping behaviours
Maslow s Hierarchy of Needs http://physicalspace.wordpress.com/category/man-society/
What do primary care providers say? I feel frustrated & hopeless because it is so much harder if the patient can not afford adequate food and you are trying to encourage self management of their diabetes If they can not afford the medication, they will not take it and they come back sicker I really do not know where to get information for the patient to help them It s time consuming enough try to navigate the medical system let alone the social system
Testing the Practical Assistant (PAW) Model Works with KHL patients across 9 primary care organizations Assists and advocates for/with individuals in meeting their social needs
Lessons Learned - Getting Started 1. Narrow the focus to the most common social determinants 2. EMR access difficult (4 different systems) 3. Develop the referral process & accompanying forms 4. Develop the communication process between the patient and healthcare providers 5. Develop a social determinant registry (KHL data collection) 6. Develop a form to track number of encounters for each patient for each issue e.g. housing
Common Social Determinants Housing Social Housing Registry Eviction Prevention (Housing Help Centre, Legal Clinic) Referrals to community resources for Rental arrears/deposit Referrals to community resources for utility arrears Transportation Knowledge of medical transportation entitlements (through ODSP) How to apply for a transit pass Social Isolation Referrals to free community social groups (exercise groups, cards, crafts, gardening etc) Knowledge of community volunteer opportunities Income Security Ontario Works Ontario Disability Support Program Government Entitlements (child tax benefit, Guaranteed income supplement, trillium benefit, etc) Budgeting Programs (KC3 Credit Counselling) Food Security Food Bank referrals Information on daily Community meals Good food box Cooking programs Literacy/Education Referrals to appropriate agencies that assist with Education and literacy issues Assistance filling in government documents
Lessons Learned - Ongoing 1. Building a more in-depth understanding of: Drug Funding Programs Medication dispensing fees Healthcare community support systems e.g. Hospice Kingston, VON, Seniors programs 2. Refining the referral process i.e. urgent and non-urgent (embedding it into the HL CCP process) 3. Developing case management skills versus crisis intervention
Urgent Referral Process Physician /NP Urgent Social Need Identified Consent for HL referral Team conference Referral to HL Project Coordinator Yes Chart Review Determine if an immediate team conference is needed? PAW Referral Schedule Home or Office Visit Interim & final progress note sent to patient s physician Questions to Consider: Will this patient need a CCP, will this be a Health Link Patient No Social Care Plan Initiated May include ongoing: - Collaboration with exiting services e.g. Veteran s Affairs - Engaging other community services e.. Independent living centre
Social Health referrals for practical assistance Social Determinant Avg. # encounters with patient Community agencies Transportation 3 ODSP, Seniors Outreach Services, Access Bus etc. Housing 5-10 Frontenac Housing Corp., Home Base Housing, Rent Banks Lilly s Place, Utility Banks etc. Income security 5-10 ODSP, OW, Independent Living Centre, Service Canada (CPP, CPP disability OAS), Salvation Army Food Security 3-5 ODSP, Salvation Army, Food bank, St Vincent de Paul, KCHC, Martha's Table Literacy 3-8 Assist in filling out forms & application process e.g. housing forms, CPP Social isolation 4 Municipal fee assistance program, Better Beginnings Other 3-8 Dental, cleaning services
Lessons Learned for Sustainability 1. Embed the role within primary care organizations 2. Social Services Worker needs access to the primary care record in the EMR 3. Develop a case management model
Case Studies
Case Study 1 Elderly female (80 s); raising teenage grandson Housing: 2 bedroom apartment with mold growing inside around the balcony Income: CPP & OAS equaling about $1,300 a month Non-discretionary expenses: Rent 980 + utilities Social System navigation: Housing, Food security, Employment Food voucher KCHC Food banks information Facilitating affordable housing Facilitating application for social housing Engage grandson in conversations about employment
Case Study 2 Women in 40 s lives alone owns her home. Income: ODSP Issue: Water pipe burst in basement. Family doctor referred and talked about the situation Client was unable to follow through on getting her water turned off, was using a wet vac instead. Client also did not have the funds to pay for the repairs. City program (Kingston Frontenac Renovates program) to help low income homeowners to complete emergency repairs and renovations Facilitated conversation with Utilities Kingston to shut water off, so the work could be done Required a lot of guidance
Case Study 3 A man in his 50 s living with his Mother 35 minutes outside of Kingston Currently on ODSP however has a lawyer pursing his WSIB as he suffered a head injury at work which has led to changes in his mental health. Client feels isolated so far away from the city and desperately wants to obtain supportive housing and work on his personal goals. Keeping in contact with Home Base Housing in regards to their waitlist in hopes Client can get moved as soon as possible
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Small Group Work
Questions for Build a Case What are the most common social determinants that you think your patients experience? What are 3 to 5 things your organization can do to start addressing some of the social determinants?
References Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management.