Social and Behavioral Domains in Electronic Health Records Rishi Manchanda MD MPH President Veronica had a chronic headache. She sought relief in numerous healthcare encounters Rishi Manchanda. The Upstream Doctors: Medical Innovators Track Sickness to Its Source. TED Books. June 6th, 2013 But Veronica was still sick. Good Care? Veronica then presented to a clinic that asked her routine questions about housingrelated risk factors, identified her problem and developed a treatment plan. Photo taken with permission Rishi Manchanda. The Upstream Doctors: Medical Innovators Track Sickness to Its Source. TED Books. June 6th, 2013 Veronica and her home got better. Propietary/ Confidential Better Care Robert Wood Johnson Foundation “Health Care’s Blind Side” December 2011 Propietary/ Confidential We mobilize and equip frontline providers with tools and training to improve care and the social determinants of health www.HealthBegins.org Social & Behavioral Domains in EHRs • Foundational vs Flexible Domains – Income Insecurity – Housing Insecurity – Food Insecurity • Capability • Design changes Foundational + Flexible Approach System Design PopulationSpecific All EHRs Frame properly to avoid stigma “Every person faces different stresses that can affect their health. We ask everyone about these issues because we may be able to help.” Health Literacy “How confident are you filling out medical forms by yourself?” • Accurate in detecting limited and limited/marginal health literacy skills. Wallace L. S., Rogers E. S., Roskos S. E., Holiday D. B., Weiss B. D. Screening items to identify patients with limited health literacy skills. Journal of General Internal Medicine. 2006;21:874–877. Income Insecurity • “Do you ever have difficulty making ends meet at the end of the month?” – Sensitivity 98%, Specificity 64% for those living below the poverty line. – Inadequate income – Low financial literacy Brcic, Vanessa, Caroline Eberdt, and Janusz Kaczorowski (2011), “Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study,” International Journal of Family Medicine, vol. 2011. Housing Insecurity • “In the past 2 months, have you been living in stable housing that you own, rent, or stay in as part of a household?” • “Are you worried or concerned that in the next 2 months you may NOT have stable housing that you own, rent, or stay in as part of a household?” Homelessness Clinical Reminder, US Department of Veterans Affairs, National Center on Homelessness Among Veterans, 2012. Contact Ann Elizabeth Montgomery [email protected] Food Insecurity Limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways. Within the last 12 months, • “Were you ever worried about whether your food would run out before you got money to buy more? • “Did you find that the food that you bought just didn't last and you didn't have money to get more?” • “Have you had difficulty affording to eat a balanced meal?” “The effectiveness of a short form of the household food security scale,” by S.J. Blumberg, K. Bialostosky, W.L. Hamilton, and R.R. Briefel (published by the American Journal of Public Health, Homeless Patient- Aligned Care Team (HPACT) at Greater Los Angeles VA • In a VA-funded demonstration project in Los Angeles, we created a clinic for homeless Veterans by adapting and integrating approaches including – Social Determinants of Health, – Community Oriented Primary Care (COPC) and – Ambulatory Intensive Caring Unit (AICU) • Target population: Homeless Veterans with complex social and medical needs and high utilization of emergency and inpatient services. 15 Integrating upstream and downstream operational models for chronic care 16 Results: HPACT at Greater Los Angeles VA Among 101 homeless, high utilizer patients We also observed improvements in 'vertical' and 'horizontal ' integration among health, housing and social service sectors. 17 Considerations in integrating Social Screening in EHRs Evaluate Patient Capability • The capability framework was created to evaluate individual well-being and its social context. • Capability is defined as the extent to which people have the opportunity to live the kind of life they value. • A capability perspective implies, e.g., that poverty should not be defined primarily by income but by scarce opportunity to pursue valued activities and goals. Ferrer and Carrasco. Capability and Clinical Success. ANNALS OF FAMILY MEDICINE VOL. 8, NO. 5 SEPTEMBER/OCTOBER 2010 Meaningful Use must address patient capability 1. What are person’s values and goals with respect to this health issue? 2. What resources are locally available? Is there opportunity to access them? How convenient are they? What is the price? 3. What personal, family, or community factors help or hinder using those resources? Ferrer and Carrasco. Capability and Clinical Success. ANNALS OF FAMILY MEDICINE VOL. 8, NO. 5 SEPTEMBER/OCTOBER 2010 Design Considerations to address Social & Behavioral Domains • Most EHRs are not care management tools. – Without these tools, clinics cannot act on, and therefore, will be less likely to ask about the social and environmental determinants of health • Clinics require support to make design changes to current practice workflows – Finding, referring and linking with community resources remains a common design challenge – Without design changes, providers will, at best, simply follow the letter, not the spirit, of Meaningful Use vis-àvis social domains. • Workforce requires training & support AND to be held accountable by their systems to ask and act on The HealthBegins ‘Community Health Detailing’ Model: Building a community-powered “Yelp for Health” to support system design change in clinics A better workforce model for the healthcare system By 2020, 25,000 Populationlevel Impact 260,000 450,000 Upstreamists ensure that their healthcare systems systematically: -Ask about where patients live, work, eat, and play using EHRs and other tools -Address upstream problems at patient, clinic, and population levels -Build bridges with upstream actors (i.e. those who work where health happens) using a data-driven approach to system design and a unique blend of skills. With tools and training, clinicians and care delivery systems can better address social factors Provider confidence to address housing & other social needs Baseline After A better standard of care is possible Photo taken with permission Propietary/ Confidential Rishi Manchanda MD MPH [email protected] www.healthbegins.org @HealthBegins The Upstream Doctors is available on Kindle, Nook, or from the iBookstore. It can be purchased for US$1.99 each.