SDOH and Access Screening Referral Tool, Access to Care Partnership

The overarching goal of this work is to streamline the departments screening for social determinants of health, improve the referral process and refer more individuals to assistance. Steps that were taken to implement this project were to assess the current scope of referral practices among all staff who make referrals, mainly frontline staff. The quality improvement project team also assessed options for how to streamline the referral process by eliminating the paper referrals and exploring options to digitalize the process. The beginning stages of the project relied heavily on the participation of staff from across the department. Programs included the Neighborhood Social Work team, Access to Care, Immunizations clinic, Tuberculosis Clinic, Women's Health Clinic, Alcohol and Drug Services, Sexual Health Clinic, Clinical Health Administration, Health Equity, and the Medicaid Administrative Claiming program.

After the process mapping was completed, the project team had a solid understanding of each individual process for making referrals across the department. The process mapping showed that every person who makes referrals for health insurance or social needs is completing the referral differently. Steps were ultimately taken to streamline this process, integrating the screening questions into the Electronic Health Record, which would ping”, or send a notification, to either the Access to Care program or Neighborhood Social Work team depending on the need. For health insurance, this provided an opportunity for the Access to Care program to work on educating clients on their options for health coverage and care. These conversations proved to be very successful for clients, as most were perceived to have a better understanding of their next steps after speaking with an Access to Care team member.

Several programs play a lead role in the development and ongoing maintenance of this program. Most notably, the Access to Care program, Neighborhood Social Work team, Immunizations Clinic team, Clinical Health Administration and Office of Planning and Quality Improvement. The Office of Planning and Quality Improvement facilitated the process mapping meeting, as well as the follow up meetings to help keep conversations on track. The Access to Care and Neighborhood Social Work team led the process from the beginning, coordinating meetings and providing feedback to the process along the way. The Immunizations clinic has played a role in the ongoing maintenance and tweaking of the project, as their staff have the direct contact with clients who are answering screening questions. Clinical Health Administration has been the primary contributor to the digitalization of the tool, integrating the screening questions into NextGen (the Electronic Health Record), working with the Immunizations team to identify the best timing for the questions to be asked, and training the Access to Care and Neighborhood Social Work teams on how to receive and follow up on a referral.

With the rapid increase of referrals that were recorded in the pilot phase of this project, Columbus Public Health has recognized the need to expand capacity within the Access to Care program to assist with the need. As of December 2018, about two months after the introduction of the screening tool, the number of referrals for health insurance through this screening tool have climbed to more than 220. Currently, Columbus Public Health is reassessing it's capacity to serve, with the goal of expanding the Access to Care program to include a Health Education Program Planner (HEPP). The HEPP would work to expand and maintain the referral program, working with individual clinics to roll out this tool across the department over the next 1-2 years. This position would also be responsible for managing data and developing reporting measures for each clinic, as well as coordinate follow up efforts with Access to Care interns. With the Department's limited budget to expand capacity beyond the addition of a HEPP, the Access to Care program will be partnering with the Office of Planning and Quality Improvement to obtain field placements for students interested in Access to Care. Columbus Public Health is one of five contracted Community Based Training Partners within a 5 state region for the University of Michigan Public Health Training Center (UMPHTC) through a large grant funded by HRSA. Students who are recruited through this opportunity will be managed by the Office of Planning and Quality Improvement, but will complete project-based work under the Access to Care program to assist with the rapidly growing referral process.

In public health, we understand that people who are poor and less educated have more health problems and die earlier than those who are richer and more educated. To make an impact on improving health equity and providing more patient-centered care, it is necessary to better understand and address the underlying causes of poor health. Columbus Public Health believes that to improve population health, health equity must be a priority and measures to reduce health disparities must be integrated into programming. Through this project, our goal is to make screening and referrals for social determinants of health part of the routine clinical process. Our objectives were, as stated:

• November 2017: Identify current referral processes of front-line staff through a process mapping meeting.

• Spring 2018: Identify the ideal referral process and work to integrate the screening questions into that referral process.

• September 2018: Train Access to Care, Neighborhood Social Work and Immunizations staff on the new, revised referral process and pilot the process for one month.

• October 2018 pilot: Increase the number of referrals for health insurance by 15% and social needs by 10%.

Each of these objectives were met over the period of one year. After the pilot kicked off, the Access to Care team proposed an average response time for follow up after an individual is referred through the EHR. The team suggested that two business days would be adequate for following up with a client who has been referred through the EHR in the Immunizations clinic. After the pilot ended, it was determined that the team did not have adequate capacity to reach this average response time. It was decided that one week would be the maximum that an individual who has been referred would have to wait for a follow up call would be on week. As the program grows in its capacity, the Access to Care team will reassess the length of time in which a response is feasible.

Specific performance measures that were used were the increase in referrals to health insurance and social needs programming, which go directly to the Access to Care and Neighborhood Social Work programs. Since the pilot kicked off, preliminary data shows that from October-November 2018, the Access program had received 166 referrals for healthcare. 40% of the clients who were uninsured also checked yes” for at least one social need. The pilot showed a 201% increase in the number of individuals being referred for health coverage and care services. Data was collected through the EHR from our Clinical Operations Officer and shared at check-in meetings with the quality improvement project team. In 2019, the Access to Care Program Manager will be trained to pull this data in order to provide monthly updates to department leadership and the Health Commissioners Office.

Modifications since the launch of this project have been made to make the screening tool more efficient and effective for both staff and clients. The original version of the screening tool listed thirteen questions, to match the questions asked on the original, paper-version of this screening process (Social Work Rx.) After receiving feedback from Immunizations Clinic staff in regards to how clients were reacting to the new screening process, as well as feedback from staff directly as to how it's impacted their intake process, it was decided that the screening tool be shortened. Since the pilot, the list of primary screening questions has been narrowed down to seven, with the remaining six questions listed as secondary, depending on the responses given in the initial screening. The narrowing of questions has allowed the Immunizations clinic staff to gather information more quickly and efficiently. ???????

One overarching goal of the Access to Care program in establishing this redesigned process was to shine light on the continuing need that residents have when it comes to health coverage and care. In 2017, 47% of Columbus Public Health's (CPH) clients, both adults and children, identified as uninsured. While CPH is a safety-net provider, the QI project team had the suspicion that individuals may be uninsured due to their lack of understanding or inability to navigate their options. The social determinants of health that impact one's ability to navigate systems more generally likely play a role in an individual's ability and to access affordable, quality medical coverage and care. This project has proven that individuals need additional education and guidance to successfully navigate through the convoluted healthcare system. Additionally, there is shared understanding that the social determinants of health are impacting health outcomes, and public health entities have a key role to play in mitigating those challenges.

After the success of the pilot in the Immunizations clinic, it was recommended by the Office of Planning and Quality Improvement that the QI project team expand this process into all clinics that operate under CPH. Additional money can be generated several way if this program were to be successful in the long term and this will drive sustainability efforts for the future. Staff who are participating in Medicaid Administrative Claiming can claim their time spent on this work through specific coding that will generate reimbursement for the department. Retroactive coverage for individuals who obtain Medicaid through enrollment services at CPH or who are connected to enrollment via follow up will allow the department to receive reimbursement and revenue from billing. Lastly, the department is exploring reimbursement through Medicaid Managed Care Organizations through the Community Pathways HUB Model, which provides reimbursement funding for organizations that are referring clients to address their social determinants of health. As this program and process evolves, the Access to Care program will seek to expand to manage outreach, education and additional expansion into all clinics. Phase two of this process will turn to outreach efforts into the community, connecting Columbus residents with enrollment opportunities as well. ???????