Healthcare Sector Activities to Identify and Intervene on Social Risk: An Introduction to the American Journal of Preventive Medicine Supplement

Gottlieb, Laura M.; DeSalvo, Karen B.; Adler, Nancy E.

doi:10.1016/j.amepre.2019.07.009

Cited by 21 publications

(16 citation statements)

References 46 publications

(15 reference statements)

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“…Stakeholders have called for more sustainable funding sources such as encouraging FQHCs to rely more on patient revenue, adjusting payments for patients' social risk, allowing flexibility of covered services, or allowing fee-for-service billing for CHWs and other team members that connect patients to and deliver social services. [36][37][38] In particular, literature supports the value of CHWs as uniquely positioned to serve as screeners and implementers, 39,40 which is consistent with our findings. Supporting professionalization and licensure of CHWs through direct billing for their services would serve to advance health care efforts to improve patients' health-related social needs.…”

Section: Discussionsupporting

confidence: 89%

Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study

et al. 2021

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PURPOSE Federally qualified health centers (FQHCs) are leaders in screening for and addressing patient's health-related social needs but variation exists in screening practices. This variation is relatively unexplored, particularly the influences of organizational and state policies. We employed a qualitative descriptive approach to study social needs screening practices at Michigan FQHCs to characterize screening processes and identify drivers of variation in screening implementation.METHODS Site visits and semistructured interviews were conducted from October 2016 through March 2017, to explore implementation of social needs screening in clinical practice. Five FQHCs were selected through maximum variation sampling. Within each site, snowball sampling identified care team members highly knowledgeable about social needs screening. We conducted 4 to 5 interviews per site. Transcripts were analyzed using a thematic approach. RESULTSWe interviewed 23 participants from 5 sites; these sites varied by geography, age distribution, and race/ethnicity. We identified 4 themes: (1) statewide initiatives and local leadership drove variation in screening practices; (2) as community health workers (CHWs) played an integral role in identifying patients' needs, their roles often shifted from that of screener to implementer; (3) social needs screening data was variably integrated into electronic health records and infrequently used for population health management; and (4) sites experienced barriers to social needs screening that limited the perceived impact and sustainability.CONCLUSIONS FQHCs placed value on the role of CHWs, on sustainable initiatives, and on funding to support continued social needs screening in primary care settings.

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Section: Discussionsupporting

confidence: 89%

Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study

et al. 2021

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“…Past research on how HCOs address SDOH has primarily been set in highly integrated settings (e.g. ACOs) [ 10 – 14 ]. Common themes included challenges/facilitators related to community, organization resources, and leadership.…”

Section: Introductionmentioning

confidence: 99%

A qualitative assessment of barriers and facilitators associated with addressing social determinants of health among members of a health collaborative in the rural Midwest

Dauner

Loomer

2021

BMC Health Serv Res

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Purpose Rural communities have unique economic and social structures, different disease burdens, and a more patchworked healthcare delivery system compared to urban counterparts. Yet research into addressing social determinants of health has focused on larger, urban, integrated health systems. Our study sought to understand capacities, facilitators, and barriers related to addressing social health needs across a collaborative of independent provider organizations in rural Northeastern Minnesota and Northwestern Wisconsin. Methods We conducted qualitative, semi-structured interviews with a purposive sample of 37 key informants from collaborative members including 4 stand-alone critical access hospitals, 3 critical access hospitals affiliated with primary care, 1 multi-clinic system, and 1 integrated regional health system. Findings Barriers were abundant and occurred at the organizational, community and policy levels. Rural providers described a lack of financial, labor, Internet, and community-based social services resources, a limited capacity to partner with other organizations, and workflows that were less than optimal for addressing SDOH. State Medicaid and other payer policies posed challenges that made it more difficult to use available resources, as did misaligned incentives between partners. While specific payer programs and organizational innovations helped facilitate their work, nothing was systemic. Relationships within the collaborative that allowed sharing of innovations and information were helpful, as was the role leadership played in promoting value-based care. Conclusions Policy change is needed to support rural providers in this work. Collaboration among rural health systems should be fostered to develop common protocols, promote value-based care, and offer economies of scale to leverage value-based payment. States can help align incentives and performance metrics across rural health care entities, engage payers in promoting value-based care, and bolster social service capacity.

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“…As the Centers for Medicare and Medicaid Services (CMS) move toward a value-based payment model accounting for social risks [ 46 ], healthcare systems and community-based settings across the U.S. are gradually implementing procedures to increase the screening of unmet basic needs and other social risks [ [47] , [48] , [49] , [50] ]. Furthermore, the CMS Accountable Health Communities initiative is a demonstration project to increase social risks screening followed by navigation to social services or community-based resources to address those needs in clinical care settings across the U.S [ 51 ].…”

Section: Discussionmentioning

confidence: 99%

Bridge to Health/ Puente a la Salud: Rationale and design of a pilot feasibility randomized trial to address diabetes self-management and unmet basic needs among racial/ethnic minority and low-income patients

Papajorgji-Taylor

Francisco

Schneider

et al. 2021

Contemporary Clinical Trials Communications

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Introduction Racial/ethnic and socioeconomic disparities in diabetes prevalence and management persist. Unmet basic needs such as food insecurity and unstable housing interfere with optimal diabetes self-management. Bridge to Health/Puente a la Salud is a randomized pilot trial designed to examine the feasibility of testing the effectiveness of addressing unmet basic needs via navigation services versus navigation plus diabetes self-management support (DSMS) on improving diabetes-related outcomes among racial/ethnic minority and low-income patients with uncontrolled diabetes. Material and methods We recruited and randomized 110 African American, Hispanic, and Medicaid patients (any race/ethnicity) with diabetes and recent hemoglobin A1C ≥ 8% to one of two 6-month interventions: 1) Navigation only; or 2) Navigation + DSMS. In both arms, practice-embedded patient navigators help participants navigate social services and community-based resources to address unmet basic needs. In Navigation + DSMS, participants are also assigned to a community health worker (CHW) embedded in a local community-based organization who provides additional navigation support and delivers DSMS. A1C and unmet basic needs data are collected via routine lab and survey, respectively, at baseline and 6-month follow-up. Qualitative interviews with participants, health system leaders, CHWs, and patient navigators are conducted to explore intervention acceptability and determinants of implementation in a health care setting. Discussion Findings from this pilot feasibility study will enhance understanding about acceptability, preliminary clinical effectiveness, and facilitators and barriers to implementation of the Navigation only and Navigation + DSMS interventions and inform refinements of the overall study design for the larger, randomized clinical trial.

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Healthcare Sector Activities to Identify and Intervene on Social Risk: An Introduction to the American Journal of Preventive Medicine Supplement

Cited by 21 publications

References 46 publications

Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study

Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study

A qualitative assessment of barriers and facilitators associated with addressing social determinants of health among members of a health collaborative in the rural Midwest

Bridge to Health/ Puente a la Salud: Rationale and design of a pilot feasibility randomized trial to address diabetes self-management and unmet basic needs among racial/ethnic minority and low-income patients

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