Social Determinants of Health Collaborative

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Social Determinants of Health Collaborative Boston Health Care for the Homeless Program Agents of Change Challenge Grant Proposal Paola Abril Campos, Jazmine Garcia Delgadillo, Joe Pereira, Maggie Sullivan
Social Determinants of Health Collaborative Boston Health Care for the Homeless Program Agents of Change Challenge Grant Proposal Paola Abril Campos, Jazmine Garcia Delgadillo, Joe Pereira, Maggie Sullivan and Amanda West November 1st, 2016 I. Team Information Name Harvard Affiliation Phone Number Paola Abril Campos Jazmine Garcia Delgadillo DrPH / HSPH DrPH / HSPH Joseph Pereira HMS MS Maggie Sullivan DrPH / HSPH Amanda West HMS MS Our Principal Innovator, Amanda West, has an MPH focusing on health care disparities, and has also been trained as a community health worker by the Massachusetts Department of Public Health. She has worked with the Ministry of Health of Guyana to create and implement their Strategic Plan on HIV, and as leader of an HIV Task Force she designed and implemented a successful curriculum to train youth as peer educators. She also has extensive experience with building staff capacity on project implementation, monitoring and evaluation. Finally, while working as a patient navigator at Boston Medical Center, she helped low-income and homeless women access medical, housing, transportation, food and other resources and therefore has first-hand knowledge of the needs of the population we are targeting. Our members come together from a variety of experiences and backgrounds that build a wellbalanced team with the rich depth and breadth of skills needed to successfully carry out our proposed project. We combine clinical perspectives, as well as public health experience in the areas of health policy, project development and evaluation. Abril comes from a background in health management and has previously implemented programs that utilize similar dashboard indicators of health, in addition to coordinating the implementation of two health care models in 300 primary care centers. Jazmine supplements this experience with proficiency in program coordination and evaluation. Amanda and Joe both bring experience in health education in terms of developing and delivering training programs for health care providers. Beyond all of the public health and program management experience on our team, we also have a solid clinical component. Maggie is a Family Nurse Practitioner with twelve years of experience who has worked with Boston Health Care for the Homeless Program (BHCHP) for over seven years and has extensive knowledge of the patient population, as well as strong connections with the staff of the health center. To date, we have had multiple collaborative activities with our partnering health center, BHCHP. Our group participation has been approved by Dr. Jessie Gaeta, Chief Medical Officer. Secondly, our entire team attended an in-person meeting with Dr. Denise de las Nueces, Medical Director of BHCHP, during which we discussed several potential projects that would support BHCHP s mission and be of use to the organization. Together, our team and BHCHP mutually agreed upon the current project proposal. Thirdly, our team engaged in a conference call with Mary Takach, BHCHP s Senior Health Policy Advisor. Ms. Takach outlined the organization s current and proposed activities to improve outreach efforts to BHCHP s super users. Ms. Takach was instrumental in suggesting areas of need where our team may be of particular use. Our topic area is primarily focused on innovating novel approaches to address the challenge of high-utilizers, of an already marginalized patient population, through the development and implementation of a screening tool for patients social determinants of health. To carry out this proposal we will also optimize multidisciplinary care teams by training case managers partnering with BHCHP from a consortium of agencies working with homeless populations across the state. II. Detailed Proposal Introduction Our partnership with BHCHP aims at integrating care and services across sectors for homeless patients to improve their health outcomes and decrease avoidable emergency department and hospital usage. There is an opportunity to address the social determinants of health of homeless patients through the effective coordination of a multidisciplinary team that integrates clinical and social services. BHCHP will soon be entering the beginning of a two-year pilot program as part of a Health Policy Commission Consortium, partnering with nine other organizations throughout Massachusetts who work with homeless persons, including primary care, behavioral health, housing agencies, shelters and social services providers. Currently, many of the case managers of these various agencies do not have training in the health needs of the clients they serve and our aim is to provide them with the training needed to evaluate and address the social determinants of health which can result in decreasing avoidable use of emergency department and hospital services. We will create a system to identify and track the top utilizers of emergency and hospital services and to train case managers, as well as other BHCHP staff, on how to assess and effectively address relevant social determinants of health. The ideas for the project were suggested by BHCHP, whose leaders identified potential areas of need. The inspiration for creating the Social Determinants of Health Collaborative is that each member of our team has prior experience and interest in health care disparities. The challenges our project solves are 1) not knowing who exactly the highestutilizers are, 2) multi-disciplinary teams not knowing how best to use data on SDH to effectively intervene with their high-utilizers, 3) not knowing which indicators contribute the most to one s being a high-utilizer, and 4) not having a way to systematically screen patients for relevant social determinants of health. The activities outlined in the following proposal are innovative in that they have not before been implemented at BHCHP and, in fact, are rarely implemented in community health centers in general. Clinicians, social workers, case managers, nurses, and behavioral health staff know their clinical encounters are often insufficient to address many of the complex needs of their patients. Being able to quickly identify and track high utilizers, and effectively intervene in their care will potentiate the clinical services of highly dedicated multi-disciplinary teams. Our team is strategically comprised of members with project management skills, capacity building backgrounds, and clinical experience to successfully carry out this project. Having a member who has direct clinical experience with BHCHP will ensure our measures are appropriate and realistic and a blend of medical and public health students will create complementary approaches and strategies. Progress to date BHCHP has begun to investigate the use of dashboard indicators to identify high utilizers and track outcomes, including costs and utilization. BHCHP has also participated in and/or implemented a number of interventions targeted to improve health and lower costs for individuals who incur the highest-costs among their patient population, including medical respite, Housing First, mobile outreach, community health workers, and harm reduction programming for active injection drug users. This project builds on these initiatives and is the first attempt to integrate case managers from non-healthcare agencies into care teams at BHCHP. As of this time no members of this proposal team have received funding for any of the activities we intend to carry out. Theory of Change Need: Every year BHCHP provides health services to 11,000 homeless people in the Boston area. These services include medical, oral, and behavioral health services as well as respite services in a 104- bed facility. While Medicaid insurance rates have increased among this population, homeless patients still experience high usage of the emergency department (ED) and frequent hospitalizations. It has been found that four times as many homeless persons experience hospitalization during a given year than the average US population, making this a significant population to target with interventions. 1 A national study of over 232 million ED visits showed that those who are homeless are over three times more likely to return to the same ED within three days of a prior visit than the average person. 2 This is indicative of an ineffective source of care for homeless patients. One study of 6,494 BHCHP patients with Medicaid coverage found that 21% of the group experienced six or more ED visits in 2010, accounting for 73% of ED visits for the group. 3 Additionally, expenditures for a homeless Medicaid-insured patient in Boston are 3.8 times that of the average Medicaid user. 4 BHCHP not only serves a patient population that, on average, disproportionately utilizes ED services compared to the general population, but also has a subset of patients who are super-utilizers. For the patient population at BHCHP, homeless individuals who have co-occurring mental illness and substance use disorders are more likely to be high utilizers of emergency care. Existing solutions: The Massachusetts Behavioral Health Partnership (MBHP) and Massachusetts Housing and Shelter Alliance (MHSA) have established Housing First in Massachusetts with the underpinning idea that housing should be a medical intervention to contain and effectively prevent healthcare costs. 5 MBHP and MHSA state that MassHealth currently addresses some medical needs of chronically homeless persons, but due to the pressing issues homeless individuals face around lack of access to food and shelter, they are unable to give priority to their health needs, leading to high use of emergency health care services. Thus, their solution to reducing high healthcare costs involves finding a permanent solution to homelessness. Meanwhile, a study on individuals enrolled as patients at BHCHP found that the majority of emergency visits among homeless adults that engage in illicit drug use were a result of Hepatitis C infections and mental health disorders. 3 Given that the high rate of Hepatitis C (along with HIV/AIDS and other blood-borne diseases) is highly correlated with using contaminated needles, 6 there are also multiple needle exchange programs throughout the Boston area, such as Addicts Health Opportunity Prevention Program (AHOPE) and the AIDS Action Committee, which also provide integrated HIV, Hepatitis and STI testing. Innovation: The primary aims of our innovation are to enhance patients health outcomes, reduce the number of emergency department visits and hospital admissions of the targeted sample by 20%, and improve access to health services across BHCHP and its satellite programs. As part of a Health Policy Commission Consortium pilot that is already underway, BHCHP will serve as a hub for a nine care team composed of medical providers and advocacy organizations to integrate care across sectors. The collaborating partners in the consortium include Bay Cove Human Health Services, Boston Public Health Commission, Boston Rescue Mission, Casa Esperanza, Massachusetts Housing and Shelter Alliance, The New England Center and Home for Veterans, Pine Street Inn, St. Francis House and Victory Programs. There are many case managers who work with each of these organizations; however, as they are not clinical staff they are generally less aware of the health issues of their patients. The goal of our Social Determinants of Health Collaborative is to identify the highest utilizers of emergency and hospital services and to train at least ten case managers from the consortium of agencies in evaluating and taking action on the social determinants of health that impact their clients care. Our innovation first seeks to meet this need by assisting in the development of a monthly data dashboard system. BHCHP plans to use the indicator to monitor numbers of emergency department visits and hospital admissions using claims and encounter feeds, as well as monitor access to primary care services and services that address social determinants of health. We will assist in developing, implementing and reviewing the data dashboard. In collaboration with BHCHP and case managers, we will identify whether we are meeting targets to reduce emergency department and hospital utilization costs on a monthly basis. In this way, we will identify if patients are accessing the services specified in their care goals, as well as identify trends that might arise at the system level. This will allow BHCHP to address social determinants of health which are hindering access to care (e.g. lack of transitional or permanent housing keeping patients from getting to appointments). In conjunction with creating a dashboard system, we will create an innovate curriculum to facilitate professional growth among case managers and BHCHP staff participating in the Health Policy Commission pilot. BHCHP has identified this as a specific need as it readies staff for the pilot. It is proposed that a week-long training be held early in this transition period. In addition, continuing education can be implemented through the creation of online modules. The overall goals of this curriculum would include 1) orienting staff on new online medical records and the dashboard to facilitate continuity of care across sites, 2) increasing education on the importance of social determinants of health and how screening tools can be used to improve patient outcomes. As part of this we will collaborate with BHCHP to select and implement a tool which will be used to screen each patient for their social determinants of health. Once the screening tool has been piloted, we will train BHCHP s multi-disciplinary teams to integrate the tool into their clinic flow. The screening tool will help BHCHP s multi-disciplinary teams and case managers from collaborating agencies to identify and reach out to their patients who are most in need, connect them to resources and track the dynamic changes in determinants and health outcomes over time. This model has implications for all stakeholders involved. For BHCHP, it will reduce acute care costs though the identification of social factors leading to increased admissions. This will also make the care provided more efficient, shifting focus away from intervention and more towards prevention of situations which contribute to high use of the healthcare system. Additionally, by using a social determinants of health screening tool, BHCHP will not only benefit from the increased pool of data that can improve patient outcomes, but will also be eligible for improved funding through MassHealth. Training case managers from across a consortium of agencies to work in collaboration with BHCHP has the opportunity to make the healthcare system much more efficient, congruent and easier to navigate for homeless individuals. Impact The intended impact of our innovation is to reduce avoidable emergency department and hospital utilization by patients at BHCHP by at least 20%. For many patients, the emergency room is an avoidable and inefficient source of care. For this initial project we will measure the reduction in emergency department use for BHCHP s 60 highest utilizers, and evaluate their connection to and use of alternative care through collaboration with patients multi-disciplinary teams which include a primary care provider, nurse and case manager. If effective, the social determinants of health screening tool can be rolled out for use with all patients across BHCHP as the health center becomes an Accountable Care Organization. Measurement of the implementation of this project will be done by periodic chart reviews and feedback to clinicians and case managers. Changing patterns in patient s use of services will be communicated back to clinical teams. This is unique among tools used in primary care, as there is often little feedback to clinicians about real gains tied to their consistent use of a screening tool. Key activities During the 15 months of program funding, the team will undertake the following key activities: 1. Conduct needs assessment of the highest-need homeless patients (Report: deliverable #1) 2. Map stakeholders (from organizations involved in homeless services) 2.1. Conduct interviews with relevant staff and stakeholders 3. Conduct first session of working group facilitated by the Agents of Change team and representatives from the Social Determinants of Health (SDH) Consortium (including health staff and administrators at BHCHP, representatives from housing and homeless service organizations and a patient representative) in order to reach a consensus about the psychosocial and medical needs of high-need homeless patients, evaluate the needed components of a screening tool for social determinants of health and agree on indicators to measure impact and effectiveness. (Document report: deliverable #2) 4. Obtain feedback from academic advisors on feasibility and effectiveness of the interventions 5. Test and implement the screening tool based on decisions of the working group 5.1. Develop strategy for implementation in collaboration with health staff and agencies involved in the Consortium 5.2. Create training materials to support implementation and compile information on Boston-area resources that staff can provide to patients based on screening outcomes (deliverable #3) 5.3. Conduct trainings with case managers from agencies in the Consortium 5.4. Launch implementation 6. Develop system to monitor the patient changes in screening indicators over time 7. Provide on-going support for the implementation of the screening tool 8. Monitor and evaluate the impact of the screening tool and resources provided to staff 9. Conduct second working group session to assess intermediate outcomes of the interventions and determine whether adjustments are needed. (Report: deliverable #4) 10. Conduct a one day follow-up training with case managers to address adjustments needed and further resources available to agencies (deliverable #5) 11. Summarize lessons learned and plan for continuous learning (deliverable #6) 12. Implement transition for future sustainability and training of new staff Sustainability/Future Plans By providing interdisciplinary teams access to previously unavailable data, the dashboard and screening tool systems provide a strong foundation for BHCHP to target their most vulnerable patients for additional case management and other resources. Beyond the strategies that are formed within the scope of the project, the ongoing collection of data will allow team members to anticipate and assist BHCHP to help make the case to policymakers about the resources needed to reduce avoidable utilization of emergency department and hospital services for high cost, high needs homeless populations. Training of new staff in the use of the screening tool and social resources can eventually be integrated into onboarding protocol and responsibility for ongoing evaluation will be taken on by the current multi-disciplinary clinical teams. Management and Communication As the PI, Amanda will be responsible for regularly reporting all progress to the Center for Primary Care. Meanwhile, given her extensive role with BHCHP and her nursing background, Maggie will serve as the main liaison between the team and BHCHP as well as the clinical advisor. Jazmine has experience in collaborating with and evaluating community health projects, and will serve as the community health intervention expert. Abril has much experience in addressing issues related to chronic disease and will serve as a health indicators specialist. Joe will head development of the training curriculum. Given the diversity of all of the team s members and the value each one brings to the team, we will operate in a democratic manner, allowing each member to develop a new skillset whenever the opportunity is available, while taking advantage of the diversity of strengths each member brings. As a team, we will have monthly, in-person
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