Behind The Scenes of Accountable Health Communities, SDOH Screening Model

October 24, 2022 - Healthcare organizations nationwide are clamoring over social determinants of health (SDOH) screening and intervention strategies nowadays, but that wasn’t entirely the case even five years ago, according to Steve Miff, MD, the president and CEO of Parkland Center for Clinical Innovation (PCCI).

But that’s exactly what Miff was focused on in May of 2017—and even years prior to that—when PCCI joined the Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities (AHC) model.

“If you think about back five years ago, the whole concept of social determinants of health and how you weave those into clinical practice and what the impact would be was still very new,” Miff told PatientEngagementHIT in a recent interview. “We were fortunate to be awarded as one of the bridge organizations for North Texas.”

As one of those bridge organizations, PCCI got its hands on social determinants of health screenings written by CMS, catering to understanding needs for housing, food, and transportation, among other factors. Those screenings were somewhat prescriptive, Miff explained, but PCCI otherwise got ample flexibility to build out its own best practices for flagging and addressing SDOH.

“The scope of this program was to really test how you screen and navigate high-risk individuals for their social and economic needs,” Miff explained. “And by doing that, does it make a difference in the way healthcare is being utilized? If we can identify these social and economic barriers to health, and they are being addressed, can we help individuals to be healthier and to be able to proactively address their medical condition in a way that does not require downstream utilization of the emergency department?”

The answer to those question is an overwhelming yes, Miff and colleagues recently published in the New England Journal of Medicine Catalyst. PCCI’s work brought together 17 clinical sites and 100 community-based organizations (CBOs) to comprise the Dallas Accountable Health Community. During the five-year program, the partners screened 12,548 individuals and flagged over 19,000 SDOH needs.

And through social services referrals to the CBOs, PCCI and its partners saw patients gain access to food sources, housing services, and other SDOH needs. That totaled to nearly 200,000 in food, the researchers reported, and nearly $540,000 in utility and rent assistance.

That success came with a lot of trial and error, Miff said. Although CMS gave its bridge organizations the SDOH questionnaires it wanted them to use, it was up to the bridge organizations themselves to determine everything else.

“It left it up to each organization and bridge to figure out where and how and when you do those screenings and those interventions. And that was part of the tremendous learning,” he stated.

Conducting SDOH Screening

Although CMS gave bridge organizations the actual screening questions to assess SDOH, organizations were in charge of determining everything else. And in a lot of ways, that was the hard part.

What’s the best way to explain SDOH screening to patients who are more used to discussing clinical needs with providers? Should patients fill this out on a paper- or tablet-based survey, or should clinicians walk through the questionnaire with them? And at what point during the clinical encounter—and in which setting—should these surveys happen?

PCCI learned about that timing and setting quickly. The organization knew it wanted to zero in on individuals with complex medical needs and above-average healthcare utilization. Using advanced patient-level analytics, PCCI identified patient risk based on having two or more emergency department (ED) visits in the last 12 months and certain sociodemographic characteristics.

“At first, we were trying to do screenings when they were in the hospital or EDs,” Miff said. “That is complicated for many reasons.”

For one, when a patient’s in the ED, ED providers need to meet clinical needs quickly. SDOH screening, although important, can’t get in the way of that. And from the patient perspective, ED-based SDOH screening doesn’t make for a good healthcare experience. The last thing a patient wants to discuss is their transportation needs, Miff said, because the patient is worried about their health right then and there.

“We found out that doing screenings telephonically 24 to 48 hours after the patient had a clinical encounter—an inpatient stay, ED visit, primary care visit—was the perfect window,” Miff explained.

For one thing, patients are back in their homes, which is a significantly more comfortable environment, increasing the odds that patients will answer all of the SDOH questions. PCCI also ensured the call had caller ID attached to it, so patients saw it was Parkland dialing them. That increased answer rates, he said, and also made patients feel as though they were being followed up with.

Staffing, too, was important, said Jacqueline Naeem, MD, PCCI’s medical director and one of the NEJM Catalyst article co-authors. Not only were the community health workers (CHWs) staffing these calls bilingual, but it was the same person every time a patient got a follow-up SDOH screening call.

“We wanted to make sure that we were able to provide that follow-up, those monthly follow-up calls, and we weren't just getting lots and lots and lots of new people without being able to continue that care as we wanted to,” Naeem told PatientEngagementHIT.

PCCI also tracked information about how long it takes to conduct an SDOH screening call and how long it takes to conduct follow-ups. This helped PCCI report to CMS how much the organization could handle monthly, as well as track the optimal caseload for CHWs who had to touch base with current clients, connect with new ones, and build and maintain their base of CBO contacts.

Connecting with community-based organizations

Flagging patients for SDOH needs was only half the work; once PCCI identified a social need, it was crucial to connect patients with a social services provider that could fulfill that need. Closing the loop instills patient trust in the process and is, of course, the end goal of SDOH work.

Naeem said CHWs are instrumental in this work. As a cohesive team, CHWs help to build a large pool of CBOs that can fulfill the needs of patients.

But PCCI can’t just endlessly refer patients to CBOs; these are tight-margin organizations that need the support of healthcare organization partners.

“We can send as many people as we can to the community-based organizations, but they are the ones that are really providing the services and making a difference,” Naeem explained. “So, we absolutely want to make sure that we are supporting them and have a great relationship with them.”

Fundamental to that relationship-building was making room for CBOs on PCCI’s AHC advisory board.

“That was really helpful because we've got the insights and heard what was going on in the community from those organizations,” Naeem added.

For example, CBOs could notify the advisory board when there are new funding changes, giving them more capacity to fulfill SDOH needs—or less capacity when funding dries up.

Naeem added that being present and visible through volunteer hours, which usually entailed data entry, was also essential because it helped build goodwill and forge a stronger relationship.

But it’s not just the interpersonal relationship; technology is woven throughout this entire relationship, Miff said. PCCI used Pieces Iris for SDOH case management, and that helped streamline the referral management process. Most of the CBOs that PCCI worked with were already on that particular IT platform, Miff said, making it easy to coordinate across PCCI and social services.

The CMS grant that came as part of the AHC bridge organization designation helped pay for the licensing fee for CBOs that were not already on the technology and helped PCCI support CBOs adopting it.

The case management tool didn’t just enable a warm handoff from CHWs to the CBOs, Naeem added. It was also a place for PCCI and organizations to store documents like driver’s licenses or W2s that demonstrate income. That’s essential because eligibility is a moving target depending on what kind of funding the CBO has at the moment.

Storing documents in the case management tool lets CHWs learn right away if a patient qualifies for a certain CBO, preventing a situation in which an individual gets turned away from a service.

Quantifying impact

Measuring the effect of SDOH intervention helps build an evidence base and prove return on investment for a new way of looking at medical care.

For PCCI, quantifying the impact of SDOH intervention meant looking at the health of patients when they started the program, factors related to patient navigation, and the utilization before and after the intervention. From there, PCCI was able to put a dollar amount to cost savings.

But, notably, something happened in the middle of the AHC model years: COVID-19. During that time, the healthcare industry nationwide saw a drop in emergency department utilization, mostly because patients wanted to avoid getting the illness.

That means PCCI couldn’t tell whether lower ED utilization was the credit of its SDOH work or the pandemic, Miff pointed out.

PCCI built patient “avatars” to compensate for this issue, helping researchers determine what healthcare utilization could have been if the pandemic wasn’t a factor.

“That by itself is super unique, and that's what I think gave the results a lot of validity because you are able to tease out this component,” Miff said.

That’s going to be important moving forward as more grant programs seek to build an SDOH evidence base. There will always be extenuating circumstances that can skew study results, Miff said, so this type of avatar modeling will help overcome abnormalities in test results.

Ultimately, PCCI’s modeling showed that cost reduction across a 24-month period for patients receiving SDOH navigation was 7.7 percent, with the total cost profile of a patient going from $398.80 to $367.85.

But the impacts go further than that, Naeem said. In qualitative patient-reported outcomes yet to be published, the PCCI team found that the SDOH navigation improved patients’ perception of their own health and well-being.

In a 400-participant survey, 72 percent said they think their health improved as a result of the program, the PCCI researchers said in data sent directly to PatientEngagementHIT. Sizeable proportions also said the program motivated them to access primary care, and around two-thirds said their SDOH needs were resolved as a result of the program.

The CMS program is over, but PCCI said it wants to continue work in this area. The AHC model only focused on the Medicare and Medicaid populations, but Miff pointed out that uninsured people will benefit greatly from social services navigation as well. The work behind doing that will be arduous and will require PCCI and its Dallas Accountable Health Community partners to find funding and rebuild its social services infrastructure.

But the ripple effect will be enormous, Naeem pointed out.

“We know how many individuals we've helped, but the individual generally has a family around them. If we are providing resources for food or utilities or housing, we are only measuring that one person, but we know there is a family,” she concluded. “When we think about that, it becomes even more and more meaningful to address these needs.”