08-09-21 SDOH Referral RoundTable Discussion

Tiger Team SDOH Referrals Roundtable 8.9.21.pdf

Discussion Questions: 

1.How many SDOH referrals are you making per week? 

• • Not sure. We do not have a formal way to track referrals. It seems like I work with at least 6-12 patients per week.

  • 1-3
  • 1-2
  • 2-3

  • 3-5

  • 6-8
  • 21

  • unknown by HCCN

  • Average of 3 per week

  • None yet

  • Each care facilitator interacts w30-40 clients/week. I estimate 15 referrals minimum

2. What type of SDOH referrals are you making?

• Our organization has a lot of mental health case managers. We have a lot of patients that get services from both programs and their managers deal with more of these referrals.
• housing/food

• Insurance, food stamps, Medicaid applications, transportation assistance, prescription assistance, and some housing.

• We make internal referrals for all pts with identified needs.  then care coordination decides whether will be done in-house or outside

• A shockingly high number of Domestic Violence

• Transportation, food, housing- 86% of referrals for housing

• Food, housing, transportation, job support, parenting services, county/state program

• Housing, transportation, mental health counseling, psychiatry, food, elderly services, long term care, financial support, insurance

• We instituted PRAPARE on 1/1/21 and have had over 1700 patients referred to Case Management. The 21 number is an estimate of how many are needing referrals to outside entities

• Food, transportation, housing,

• housing Medicaid apps disability apps transportation

• We handle a lot of things internally, but sometimes we are referring to different departments. The hardest thing is defining a referral, such as things handled internally or externally.
• We struggle with non-healthcare services because those are not in our EHR
• Front desk staff gives patients their PRAPARE"s at their initial visit. They are returned one week later to CHW's, sometimes longer.
•  We’ve started using PRAPARE late last year. We aren’t documenting interventions/referrals in a standard way just yet. Interested to hear what others are doing.
• We have a lot of patients that also have behavioral health case management. It is case specific on which department takes the lead with helping patients getting connected with resources and it then involves care coordination to avoid duplication
• The idea in theory is beneficial. The workflow and process for referring patients is challenging.

3. What is your workflow for identifying SDOH referrals?

• Patients are screened once/year.  The template automatically creates the SDOH referrals with the  needs information on the referral.  The internal referral is attached to the patient's chart in EHR.  The internal referral is updated in EHR as process
• PRAPARE- encounter with provider and discussion- diagnosis made (ICD 10 code)- referral made in NextGen- referral specialists forwards to social service provider
• PRAPARE in the ehr to identify needs. Work with the patient to provide connections to resources but no official referral
• Tracking is a problem because not good way in EHR
• Paper prepare or using social history section of EPIC we also made a short form listing just the domain and asking which are working at this time and which are challenging. We also have a five question screening in rioming
• Ideally, nursing completes a referral at the time the PRAPARE is given (during the intake portion of the exam), but in reality the majority are identified using the PRAPARE report in the EHR and making contact afterwards
• We are in Athena. We implemented the use of Case Management referrals for any patient with a SDOH identified on the PRAPARE. We then developed a "Level of Care" system to identify a standard of follow-up frequency by Case Management based on LoC
• The social worker reviews the PRAPARE responses from a report that runs  on Mondays.   If there are any positives a phone call is made to follow up and resources given or referrals made
• We are currently using tally sheets due to no good way to track them in the EHR.
• Internal warm handoffs to care coordinators for acute needs
• We are catching more of the comprehensive needs of clients we work w and the addition of some rooming questions has been good
• I am excited about the idea for the community care order. We use NextGen. I hope there’s a way we can use this!!
• CHW completes the PRAPARE and makes community referrals at the time of the assessment being completed.
• Our referral process needs a lot of work. I do like that pts are given a referral at the time of assessment. We have no organized way of closing the loop or keeping track of follow up.

4. What is working well with your SDOH referral process?

• We tie our referrals to diagnoses and codify our process. We are also tracking everything in NextGen.
• We catch more comprehensive needs from our patients when we use PRAPARE. And I like that we now have some room in questions being asked on every primary care visit
• Between January-June, 60% of Case Management referrals had not received any form of assistance from Case Management in 2020; which means we are PROACTIVELY identifying patients rather than reactivel
• We have had CHWs indicate the question if asked in last 30 or 60 days would make it more actionable. That has been request for modifying PRAPARE tool.

5. What challenges are you experiencing with your SDOH referral process?

• One of the problems I have had with the PRAPARE screening is that there are some life situations that will not change. For example, if someone had Medicaid or disability, these are considered a positive response on the PRAPARE but the people have an income of sorts and insurance, but there income is low enough that they will always struggle with paying bills, keeping rent/utilities paid, having a way to handle vehicle repairs, etc.  
• PRAPARE is  long. We made our own brief screen for emergent situations, but would love a verified form
• We need more Case Managers to competently handle the needs are patients are dealing with. Our organization does have a long term plan, but that does not help Case Managers right now
• Some providers are better at making referrals than others.  It would also be easier if we had technology that connected more directly to the social provider
• The time it takes to get the PRAPARE back from the patients initial screen.
• Staffing - we only have 9.5 Full Time Case Managers and so far 10K patients have been screened with over 13% having a SDOH, 277 of those are the High Level (Homeless or DV)
• We have some of our health centers starting to use UniteUs to connect to Social service providers in their community.
• We are beginning to use Unite US (FQHC from Iowa) and are working with the social agencies in our community to get them on the Platform as well
• One other challenge I could see from talking to other CHWs in the field is that every clinic has different workflows and so their needs within EHRs may be different. For example, some people have PRAPARE screenings done at front desks or within patient portals at beginnings of appointments, where as others have CHWs and/or clinic staff do this during various times during a patient appointment. I could see that become a huge influence when the word "referral" is defined.
• Has ability to complete PRAPARE within the tool but we still need CHCs to complete PRAPARE in EMR otherwise doesn't get in the EMR.
• Need workforce to support them such as CHW.  relying on provider only to do referrals sets up for failure 

6. How are you receiving results from your referrals?

• Unfortunately, we are currently limited to chart audits. The reports only tell us if a referral has been made when it is needed.
• We do a lot of result work in following up with the patent.  We also  establish relationships w most referral agencies so we can check on status and close loop
• Currently outside referrals are a challenge that take a lot of follow up with the patient or agency.  We are hoping the Unite Us helps close this loop as it grows in our area
• Our results are sporadic depending on if we hear back from the patient.
• The social service provider fills out a template that we created and returns it to the referral specialist at the health center
• I think it is a case by case situation. Some are patients self-reporting and some are from other referral sources.
• We are about to go live using Aunt Bertha in EMR.  Allegedly referrals will go directly from EMR to agency and result will show in EMR (Heidi)
  

7.How are case management services delivered?

• We have behavioral Health in house, but we refer out for coaching and housing counseling.  The referred out work creates plans with the patients and sends those plans back to the referral specialist to upload to the EHR
• We have 4 Family Practice centers that each have 2 Case Managers, then 2 specialty clinics (Psych & OB) each with one CM...when we are fully staffed...
• We have some official "case managers" who are connected to insurance standards.  I have care facilitators in primary care clinics who take warm handoffs and other referrals from pcps.  They work in person with patients and over the phone. We work with someone until goal is met and sustained (3 therapy appointments, housing for 3 months...) 
• A few years back, we merged out Outreach & Enrollment staff (ACA) with Case Management, but we are planning to go back to 2 separate positions in order to allow Case Managers to focus more on the complex needs and O&E staff focusing on insurance