Written by: Center for Care Innovations

To thrive under the new payment models, health centers will need to start using social determinants data to target the right care at the right patients. As part of CCI’s Cultivate Fund program, Petaluma Health Center has refined its workflow to collect this data using a waiting room kiosk, exam room questioning and their patient portal.

Time for Action

For years healthcare organizations and policymakers have talked about the huge impact social factors play in health outcomes. But now the adoption of new payment models by many safety net systems means that health centers have to move beyond talk, to action. Payment reform incentivizes health centers to make sure patients are getting the services they need to avoid the costly and chronic medical conditions that often come with a poor socio-economic situation, with poor living conditions or lack of access to healthy food. To do so in a way that is cost effective enough to allow them to thrive under new payment models, providers need to start collecting and using data on social determinants of health (SDOH).

The Infrastructure for Data

As part of a project supported by CCI’s Cultivate Fund program, Petaluma Health Center set out to incorporate the collection and use of SDOH data into their daily workflows. They began by adding fields for different social determinants, such as housing and food access, into their electronic health record system. Then they created a questionnaire with which to collect this information from patients. Once they had the data, they would use the Tableau visualization software to create maps and other graphical representations of the data that allow them to target interventions in the community.

Different Forms of Collection

Petaluma used a number of different vectors approaches to get patients to answer questions about their food security, housing, income and other factors. The questionnaire was incorporated into the iPad kiosk in their waiting room, allowing people to fill it out during a check-in prior to their appointment. They also built the questionnaire into the process of signing into their patient portal, though this was stymied somewhat by technical issues. And finally Petaluma had medical assistants ask patients the questions in the exam room, particularly during new patient visits or wellness visits.

Triaging for Social Needs

Once they got patients to fill out the questionaire, Petaluma needed a consistant way to organize their response to meet each patient’s needs. They created a system to categorize each patient’s SDOH risks and the actions that would be taken in each case.

They sorted patients into “mild,” “moderate,” and “severe” buckets. Mild patients had only one or two social determinants needs. Moderate patients had three or more SDOH issues, and would be paired with a patient navigator for a one-on-one session to direct them towards help getting housing assistance or other services. Severe patients combined SDOH issues with complex medical problems resulting in five or more ER visits or two hospitalizations in the six months, or an uncontrolled chronic illness. Severe patients were given a case manager to work to address their total set of health needs.

Acting on Information

Petaluma has incorporated reviews of patients social determinants needs into their care team huddles, so that they can plan for which patients may need time with a case worker or navigator, which patients might need food assistance, and so forth. Based on the information they gather they provide referrals to social services.

They also used Tableau to look at the larger picture of their community created by their social determinants data. This gave them the ability to look at health disparities that they can tackle with new programs or changes in their practices by focusing efforts in particular zip codes or neighborhoods. It can also help them begin doing “upstream” work finding commonalities that can help them identify health threats in the community.

Lessons from Practice

  • It was vital to select the right social determinants metrics to ask about. Because these fields would be incorporated into their EHR, there was not room for being flexible about what social factors they asked about. Petaluma needed to find a balance between measure that would be useful for them, and questions that patients would be comfortable answering. Petaluma reviewed published standards and worked with their patient and family advisory council as well as their fellow Innovation Hub at West County Health Centers to pick their metrics.
  • Petaluma learned not to rely on a single method to collect data from all their patients. Not everyone wanted to use the iPad kiosks, and not everyone would fill out the survey on the patient portal. Having a number of alternatives was the best approach. Furthermore, significant time was needed to gather enough data to make programatic decisions.
  • It’s vital to be sensitive about doing social determinants needs screenings on children.

What’s Next?

Because of the success of the waiting room iPads, Petaluma has added four additional kiosks. They are also working to get past the technical issues that slowed the incorporation of SDOH surveys into their patient portal. In the bigger picture Petaluma is looking for ways to more seamlessly connect patients to the services they need, as well as incorporate community data into their SDOH work.

Learn More

  • Petaluma Health Center is a California FQHC that provides primary medical care and mental health services to residents of Petaluma, Rohnert Park, Cotati, Penngrove and the surrounding areas. Visit their website: phealthcenter.org
  • Petaluma has participated in a number of CCI programs, including the Innovation Catalyst and the Innovation Hubs programs.
  • Read the full case study by White Mountain Research Associates here.