Accelerating the Implementation of Social Determinants of Health Interventions in Internal Medicine

Byhoff, Elena; Freund, Karen M.; Garg, Arvin

doi:10.1007/s11606-017-4230-8

Cited by 38 publications

(39 citation statements)

References 24 publications

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“…The Six Core Elements is not a model of care but a structured process that can be customized for use in a busy practice and applied to many different types of transition care models 142 and settings such as transition and young adult clinics and programs. The intensity of the HCT intervention can be guided by several aspects, such as the complexity of the health condition, the social determinants of health, 143 and adverse childhood experiences 144 of the youth and young adult. For example, if the youth has many comorbidities and/or there is poor adherence to care before the transition, more supports are likely to be needed during and after the transition process.…”

Section: Updated Hct Processesmentioning

confidence: 99%

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

2018

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Risk and vulnerability encompass many dimensions of the transition from adolescence to adulthood. Transition from pediatric, parent-supervised health care to more independent, patient-centered adult health care is no exception. The tenets and algorithm of the original 2011 clinical report, "Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home, " are unchanged. This updated clinical report provides more practice-based quality improvement guidance on key elements of transition planning, transfer, and integration into adult care for all youth and young adults. It also includes new and updated sections on definition and guiding principles, the status of health care transition preparation among youth, barriers, outcome evidence, recommended health care transition processes and implementation strategies using quality improvement methods, special populations, education and training in pediatric onset conditions, and payment options. The clinical report also includes new recommendations pertaining to infrastructure, education and training, payment, and research.

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Section: Updated Hct Processesmentioning

confidence: 99%

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

2018

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“…First, there has been increased attention in the medical community to the importance of SDOH in the peer-reviewed literature and the lay press. 11,35,36 Since the implementation of WE CARE screening began in 2015, the American Academy of Pediatrics formalized guidelines to screen for poverty-related conditions at well-child visits. 37 There have also been significant policy and payment shifts toward identifying and addressing SDOH in health care, including the Accountable Health Communities model and the Massachusetts Medicaid demonstration project.…”

Section: Discussionmentioning

confidence: 99%

Provider and Staff Feedback on Screening for Social and Behavioral Determinants of Health for Pediatric Patients

et al. 2019

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Introduction: Screening and referral for Social and Behavioral Determinants of Health (SDOH) are increasingly recommended in clinical guidelines and consensus statements. It is important to understand barriers and facilitators to implementation of standardized SDOH screening and referral practices, as well as the scope of current existing SDOH screening.Methods: We conducted a mixed-methods study to understand the current state of SDOH screening and to assess the barriers and facilitators to implementing a standardized SDOH screening and referral practice in Boston community health centers (CHCs) for pediatric patients. We requested all SDOH screening documents from 15 Boston CHCs and conducted provider and staff focus groups at intervention sites of an SDOH implementation pilot in Boston.Results: All CHCs screened in some form for SDOH, but there was no agreement on which domains to screen. Participating CHCs screened for a mean of 8 SDOH domains (range, 5 to 16). Overall, 16 SDOH domains emerged. From the focus groups, 5 themes emerged: 1) provider perspectives, 2) work flow, 3) prior experience, 4) site resources and staffing, and 5) sustainability. There was little agreement among participants within each theme, as all were seen as barriers and facilitators depending on the respondent.Discussion: This study highlights the various SDOH screening methods currently used in Boston CHCs, and the need for workflow and process individualization of SDOH screening and referral. Providers and clinical staff should be part of the discussion when implementing SDOH screening and referral procedures to ensure appropriate work flow, staff buy-in, and to maximize resources available. (J Am Board Fam Med 2019;32:297-306.)

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“…The activities include the completion of a structured social needs assessment, which is begun at the start of cancer treatment and is updated with each transition of care, such as the initiation of chemotherapy, surgery, or radiation therapy, or according to a patient's need. There are now standardized screening tools for social determinants . In addition to screening tools, there are local and national online tools that provide linkages between social needs and free or low‐cost community resources that navigators and patients can access to address identified needs .…”

Section: Resultsmentioning

confidence: 99%

“…There are now standardized screening tools for social determinants. [28][29][30][31][32][33] In addition to screening tools, there are local and national online tools that provide linkages between social needs and free or low-cost community resources that navigators and patients can access to address identified needs. [34][35][36][37] Several of the activities are focused beyond direct interactions with specific patients.…”

Section: Resultsmentioning

confidence: 99%

“…Evidence within primary care has documented positive health impacts from screening for social needs and providing resource referrals within the community to mitigate these needs. 29,52 A number of screening tools have been published [28][29][30][31][32][33] ; the supporting information provides the screening tool that we adapted from the literature and tailored to our community needs.…”

Section: Continuedmentioning

confidence: 99%

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Standardized activities for lay patient navigators in breast cancer care: Recommendations from a citywide implementation study

Freund

Haas

Lemon

et al. 2019

Cancer

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Background There is a need for guidelines on patient navigation activities to promote both the quality of patient navigation and the standards of reimbursement for these services because a lack of reimbursement is a major barrier to the implementation, maintenance, and sustainability of these programs. Methods A broad community‐based participatory research process was used to identify the needs of patients for navigation. A panel of stakeholders of clinical providers was convened to identify specific activities for navigators to address the needs of patients and providers with the explicit goal of reducing delays in the initiation of cancer treatment and improving adherence to the care plan. Results Specific activities were identified that could be generalized to all patient navigation programs for care during active cancer management to address the needs of vulnerable communities. Conclusions Oncology programs that seek to implement lay patient navigation may benefit from the adoption of these activities for quality monitoring. Such activities are necessary as we consider reimbursement strategies for navigators without clinical training or licensure.

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Accelerating the Implementation of Social Determinants of Health Interventions in Internal Medicine

Cited by 38 publications

References 24 publications

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home

Provider and Staff Feedback on Screening for Social and Behavioral Determinants of Health for Pediatric Patients

Standardized activities for lay patient navigators in breast cancer care: Recommendations from a citywide implementation study

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