In 2020, MICMT will be launching new course curriculum to include: Introduction to Team Based Care, Patient Engagement, MAT Orientation, Palliative Care, and Specialty Care. The presentation reviews the new framework, training opportunities, and training reimbursements.
2019 Best Practice Awards Submission for SDoH
A plan was developed as a healthcare system which guaranteed that patients with or without a network primary care provider were seen for follow-up with seven days of discharge. This was accomplished by: 1) maintaining designated appointments on PCP schedules every day; 2) scheduling patients with the hospital based clinic provider for hospital follow-up if their PCP could not accommodate the appointment or the patient did not have a PCP; and 3) developing a transition plan to a network PCP for patients who did not have one prior to accessing hospital services.
2019 Best Practice Awards Submission for SDoH
There was an identified need to screen all patients for SDoH, as previously only screening patients who were receiving care management services. The PRAPARE questionnaire was designed on the iPad for patients to complete during check-in process to minimize impact on time in exam rooms. Patients with issues identified through the screening met with either a care manager or community health worker through a warm handoff, and were provided support or connected to community resources as needed.
2019 Best Practice Awards Submission for SDoH
TPA's mission includes improving the health and reducing cost for the patient population. Best practice workflow for SDoH screening was defined and implemented. 88% of patients were screening, but only 42.7% received a referral when they had a positive screening. The ease of identifying and referring patients was determined as a barrier to referrals. An SDoH health database vendor was selected (NowPow, community resource database) and implementation has begun.
2019 Best Practice Awards Submission for SDoH
The goal of the program is to identify patients who may need extra resources that may not be referred through the Care Management referral process. The program was developed by the Care Management team with a SIM template serving as the guide to create their own screening tool. A SDoH survey is performed on all patients; and for those who report a positive response, staff will begin the process by offering community services information materials and connect to a Care Manager.
2019 Best Practice Awards Submission for SDoH
A Social Determinants of Health Screening project was implemented at Kids Creek Children's Clinic between June 2017 and October 2017; and is still on-going and expanded. During the implementation, the Social Needs Screening Tool was completed by 1863 patients/parents and a Community Resources Guide was distributed as well. Additional referrals were made to the Care Manager for more intervention.
2019 Best Practice Awards Submission for SDoH
The first part of the program involved establishing and implementing a standardized SDoH screening tool into the workflow. The second part of the program was using the information to identify patients with social needs and link them to appropriate community resources. Lastly, education and training was provided to the practices with the objectives of defining SDoH, explaining the five domains of SDoH, understanding the importance of screening, describing the screening and documentation process, utilizing proper tools and resources, and identifying patients in need of follow-up.
2019 Best Practice Awards Winner for SDoH
The implementation of the 15-question SDoH screen occurred in June 2018. The goal was to identify patient needs and link them to community resources to address their needs. Through July 2019, 50,338 SDoH screens were administered, resulting in 4,809 unique referrals to community resources. Screenings for SDoH are being completed in 23 primary care practices.
2019 Best Practice Awards Submission for SDoH
GLOSC embarked on building a SDoH program by first hiring a Community Health Liaison whose initial role has been to ensure that the building blocks for SDoH management were in place 2019. The CHL acted as a project lead for building the program as well as personal community resource hub for practice and patient needs. In order to satisfy a resource deficit gleaned from practices without the means to resolve patient needs after they were screened, practice workflows were assessed, false staff perceptions regarding SDoH were addressed, unique processes were developed, and an extensive repository of public and private community resources was built.
2019 Best Practice Awards Submission for SDoH
In May 2019, a pilot of an electronic SDoH screening process began; expanding to additional practices in July. To ensure high-risk patients received appropriate follow-up, the Centralized Disease and Care Management team was implemented to assist with a number of processes including follow-up calls for all patients with positive screens. This new approach ensures patients receive appropriate resources while allowing practice care management teams to work at the top of their license and focus on chronic care management.