Case Study: Boosting Teamwork Around Social Needs Screening at Asian Health Services

Project Activities

Phase 1: Learning from the PRAPARE pilot

At the start of the ROOTS program year, more than 400 PRAPARE screens had been collected through the previous PREPARE pilot by four care teams: patient navigators in a primary care clinic, the HIV intervention care team, behavioral health case managers, and the Care Neighborhood community health workers. Based on interviews with 30 patients screened during the past pilot, the AHS team learned that most patients were comfortable with the screening and had high trust in AHS, especially with the behavioral health team. However, rates of success with assistance and types of assistance offered differed by care team: 80 to 90 percent of patients screened by the behavioral health team had been linked with services, compared to fewer than 25 percent of patients screened in primary care.

“What this project has uncovered— just through the screening and the response— is that we may already have some of these answers, we just need to share them.”

– AHS Chief Deputy of Administration, Programs

The AHS team believe these differences in part reflected how available staff were to work with patients on social service connections, but also differences in teams’ knowledge about available resources. For instance, because of the high housing needs among HIV-positive patients, the HIV team was very familiar with housing resources and had access to a monthly housing availability list that other teams were unaware of. And one behavioral health case manager had found a way to get patients into hotels when they needed temporary housing, something that others did not know was possible.

To share this information and ensure all patients benefit from this knowledge, staff from different implementation teams started talking to each other more routinely to identify and exchange resources. For example, the HIV program manager and care staff now attend the monthly behavioral health case management meeting.

In addition to ensuring that knowledge about resources were being shared internally, the team assessed the appropriateness of referrals for their patient population. They examined geographic proximity, eligibility requirements, and language access, knowing these factors would be of high relevance to their patient population. They also contacted community-based organizations directly to better understand how patients might experience the resources they were offering. They then developed a list of vetted resources that now forms the basis of all referrals for the entire staff.

“Even if it’s five miles away rather than two miles away, but we know that they have Cantonese, I would prefer they have to go the five miles, because at least they can get help.”

 -AHS Community Services Manager

Phase 2: Developing a More Effective and Coordinated Screening and Referral Workflow

Incorporating the PRAPARE screening into established clinical workflows brought unique challenges to both patient navigators and case managers. Initially, navigators reported that some patients were surprised by the personal nature of the screening questions or became emotional during screening, as they shared their stories of hardship. Increased screening also meant behavioral health case managers were suddenly busier — they needed more time with their own patients and were receiving more referrals from patient navigators. Additionally, case managers working with HIV-positive patients were frustrated by the overlap between some of the PRAPARE screening questions and other grant-mandated surveys, worrying about patient “survey fatigue.”

To respond to these challenges, the ROOTS project team worked with the teams implementing PRAPARE to develop a risk-stratified referral algorithm based on complexity and required level of support. Depending on specific criteria, patient navigators were trained to address more straightforward needs and to refer patients with more complex needs to either case managers or member services.

Patient navigators also met frequently with their supervisors to review how to ask PRAPARE screening questions efficiently and compassionately. To address concerns about duplicate screening questions, the team decided that only non-duplicative screening questions would be asked.

Phase 3: Partnerships

A key success for the ROOTS team was developing a new partnership with the Alameda County Community Food Bank to hold a monthly food distribution event in a park across the street from AHS administrative offices and a few blocks from AHS clinical sites in Oakland’s Chinatown district. Prior attempts to partner with the food bank to distribute food in Madison Park had not been successful due to the food bank’s concerns that not enough community members would actually use a Chinatown distribution site. At the same time, AHS patients reported not using food bank because of language barriers, lack of culturally-appropriate food, and eligibility concerns.

The ROOTS program’s focus on partnerships helped encourage AHS’ Community Services Manager and a ROOTS team member to reach out to the food bank again and discuss new partnership strategies. As a first step, the two organizations successfully partnered to provide snacks for AHS youth programs. They then ran a trial food distribution event with fresh fruits and vegetables from the food bank during an AHS health fair in Madison Park. The trial demonstrated that there was strong interest in food distribution at this site and convinced the food bank that it was worthwhile to do a monthly food distribution at this site. The trial, and surveys AHS conducted on site, also helped AHS better understand attendees’ food preferences. For instance, for future events they focused on culturally appropriate foods (e.g. sweet potatoes instead of regular potatoes) and included fewer canned goods, as participants preferred fresh produce. AHS now distributes food from the food bank to as many as 160 community members every month.

Next Steps

Moving forward, AHS plans to continue expanding PRAPARE screening activities and resource referrals to more clinical teams and sites, as well as work to improve referral outcomes tracking. They also continue to advocate for patients at a systems level. For example, they have taken an active role in fighting expansion of the federal “public charge” rule that would discourage immigrants from using public services. They are also actively exploring ways to increase the availability of affordable housing and to protect the Chinatown community from further displacement.

AHS Advice for Implementing Social Needs Interventions

• Increase cross-team communication. Prior to the ROOTS grant, select AHS teams worked relatively independently to assist patients with social needs, often unaware of the resources that others were using. The ROOTS project led them to increase cross-team communication to ensure all patients benefit from staff knowledge and expertise.
• Create standard workflows and ensure staff have the skills and capacity to meet new demands. To handle the influx of patient referrals and offer more consistent resources to patients, AHS redesigned team-specific workflows and developed a risk-stratified referral algorithm. Patient navigators are now trained to manage a wider range of needs, and clinic staff have clearer guidelines about when to refer patients to patient navigators or escalate referrals to case management.
• Be patient and persistent when building partnerships. Partnerships require time, patience, and persistence. Both the Alameda Food Bank and AHS clinic leadership were interested in working together, but concerns about interest in the foods available through the food bank had stymied previous partnership efforts. The ROOTS project gave the team time and space to persevere in reaching out to the food bank and to demonstrate demand for the groceries the food bank could provide. The result is a partnership that is a win-win for both organizations.
• Start small and take your time. Start small so you can test changes before scaling up. Give yourself the time to test different approaches. Gather data from patients and staff so that you can develop processes and interventions that work well for your context.