Resource Library

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.

2019 Best Practice Awards Submission for Reduction in Utilization

The Advanced Heart Failure Clinic identified a need for additional patient support and a lack of care coordination between the PCP, hospital, and specialty. The decision was made to embed a full time RN Care Manager into the Advanced Heart Failure Clinic. In the first year, the RN CM conducted 1,826 visits with patients. He provided care coordination and supported the Heart Failure Clinic interventions with these patients. Analyzing a cohort of 25 patients, results of this work demonstrate a 43% reduction in ED utilization and a 48% reduction in Inpatient Admissions.

2019 Best Practice Awards Submission for Reduction in Utilization

Centralized support was provided for the transition of care process, initiating the phone call portion of the requirements. To date, there has been over 1,300 transition of care encounters completed on over 1,100 unique patients. This has contributed to the organization's observed decline in emergency department utilization rates. Coordination and collaboration with clinical offices ensures patients have scheduled follow-up visits and centralized supportive care management is provided to PO-specific members free of charge.

2019 Best Practice Awards Submission for Reduction in Utilization

NPO uses the PCMH-N model as the infrastructure for all work, and regarding ED visits, emphasized how specific domains, such as after hour call availability, when implemented, can help reduce ED visits. All practices were educated and reinforced this message. Additional tools were also promoted and provided to aid in the reduction of ED visits including ADT and Medication Reconciliation, patient educational posters and Care Managers. PCMH User Group meetings, site visits, e-mails, Care Manager meetings, and other methods were used so practices can share with and learn from one another. Practices now incorporate tools as soon as they are provided to continue to drive down ED utilization.

2019 Best Practice Awards Submission for Reduction in Utilization

Metro Health committed itself to reduce PCS ED visits for their patient population. Metro Health gave a network-wide, multi-faceted approach to tackle PCS ED visits by carrying open provider panels, creating walk-in appointment slots, conducting extensive marketing of primary care availability, and providing patient education on appropriateness of ED visits. Efforts were also focused to expand their care management program and engage these staff members in ED discharges.