Population Health Project: Improved Access to Social Services
The Population Health Learning Network aims to improve the health and well-being of more than 1.2 million Californians by bringing together safety-net primary care organizations to strengthen and advance their population health management strategies. The PHLN is a joint project by the Center for Care Innovations (CCI) and Blue Shield of California Foundation in partnership with The California Health Care Foundation, which launched PHLN in March 2018.
Population health management requires providing care for patients’ whole self, including social factors such as zip codes that impact their health. Social determinants of health (SDOH), which include factors related to a person’s socioeconomic status, culture, health behaviors, and environment, can account for up to 80 percent of their total health outcomes. By participating in the Population Health Learning Network, health centers LADHS and BACH increased their population health outreach by implementing tools that screen for social needs. LADHS implemented the Hunger Vital Sign screening tool, which measures whether patients are experiencing food insecurity. BACH implemented the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) screening too, which measures patients’ SDOH scores related to housing, transportation, childcare, income, domestic violence, and other social issues. Providers use this information to put patients’ physical health in context and meet patients at their level of care, often linking them to social services when gaps are identified.
In March 2020, the COVID-19 pandemic drastically altered the healthcare landscape, necessarily changing the ways that BACH and LADHS provide care. Both organizations have faced hurdles related to the pandemic, such as competing priorities, staff redeployment to focus on COVID-19 care, and budget changes. However, in the midst of uncertainty and health emergencies, staff at both organizations have made strides to continue their population health work, reflecting that they see their roles as more important than ever.
Los Angeles Department of Health Services
In the Population Health Learning Network, LADHS focused on screening for and addressing food insecurity among patients. Their project goal was to address social needs to improve clinical outcomes by linking at least 25 percent of patients who screened positive for food insecurity to relevant services. Its strategies included setting up new workflows to effectively implement Hunger Vital Sign, sharing data across teams, linking patients to social services and other community-based organizations, and improving follow-up with patients to make sure social service referrals were completed. Over time, LADHS refined its data methodology to approach the social determinants of health in the same way that it approaches other physical health concerns, creating rigorous practices around planning, committing to targets and goals, evaluating its progress, and altering its strategy as necessary.
“In medicine, formal tracking and evaluation come naturally to us around hypertension and diabetes, and this project showed that the same rigor can be used for social needs. This framework lends itself to social needs and can be done effectively with data driven, formal, goal-setting work.” – Barbara Rubino, LADHS
LADHS began its project by implementing Hunger Vital Sign in its Phase 1 Sites, which included seven clinics across five different facilities. Simultaneously, LADHS began to link many of its patients who screened positive for food insecurity. It did so by giving patients and their care teams handouts on local community food resources and/or CalFresh information sheets. Some patients were given a warm handoff to a social worker or dedicated support staff as well. Meanwhile, LADHS ensured that all patient referrals were documented in a patient’s chart in the electronic health record (EHR).
From March 2019 to March 2020, LADHS saw an increase in screening rates for food insecurity across four out of five Phase 1 sites. Screening rates across 4/5 Phase 1 sites increased from <5 percent to >50 percent of all patients checked out from primary care visits.
Moving forward, LADHS hopes to develop a formal tracking process to follow up with patients and close the loop between social service partners and their clinic. It has already made strides towards this goal by building a registry of patients who are food-insecure. It also plans to spread its method of screening and meeting social needs to other sites in the LADHS system.
“It doesn’t feel good to uncover something if we’re not able to help them, so we made sure that screening and offering resources were compounded together through training our staff.” – Barbara Rubino, LADHS
When COVID-19 hit, LADHS was faced with many challenges. Some of their staff were deployed to the response, and others who were focused on population health work switched roles to fill the gaps. Further, the spreading of the project to additional Phase 2 sites has been delayed. However, LADHS has begun to think and plan for the “new normal,” including what population health, social screening, and access to resources might look like in the future.
Adaptations in Light of COVID-19
“One gratifying yet unexpected outcome we are seeing is how the foundational work we did with PCMH teams has prepared them for navigating our system’s COVID-19 emergency response. Our PHLN work fostered a more mature understanding around food insecurity and provided a rich context for team members to ask patients questions around social needs.” – Jagruti Shukla, LADHS
According to LADHS’ staff, their focus on population health over the past two years has prepared them to respond to emergent challenges in the face of a crisis. They have climbed a “steep organizational learning curve” to get to a place where they can respond efficiently and effectively. Their organization has improved their capacity to work across internal departments and with external community agencies to better address food insecurity among other social services for their patient population. They have adapted to meet the needs of their patients through:
- Phone screenings: LADHS has been sensitive to which types of population health management work can be done over the phone. However, they are pushing forward with their food insecurity screenings in particular via phone visit.
- Food banks: When patients are identified as food insecure through phone screenings or as part of phone visits, they are referred to various food resources. LADHS has continued to provide linkages to community resources. Additionally, some sites have launched their own internal food banks, which distribute pre-packaged food in a socially-distant manner.
- Expanded use of on-site food pantries: Several LADHS sites provide social services to patients through an on-site food pantry, which provides food distributions for patients 2-3 times per month.
These services are increasingly important when many patients are suffering economically in the wake of the pandemic-induced recession. Clinic staff have found that patients are especially appreciative of these services during COVID-19, when resources have shrunk due to the economic downturn. One patient expressed gratitude when seeing a community health worker who she knows from the clinic at a food distribution. She had not applied to CalFresh before and appreciated knowing that the medical center is helping patients during COVID-19. Another patient lives far from the medical center, but appreciated that her team scheduled visits for her on the same day of food distributions. She was able to utilize Call The Car, a health care transportation service, to come to the medical center for her appointment and attended the food distribution. She explained, “Someone always calls me to let me know about the distributions taking place on campus.” A third patient arrived at the distribution after receiving an outreach mailer from her clinic, which encouraged her to attend. She does not know if she is eligible for Calfresh because of fears in applying with family members with no documentation, but appreciated learning more about the enrollment process from LADHS, thus assuaging some of her fears.
“Certain facilities that are engaged in this work are pressing on over the phone, calling patients to do screenings. The work has continued and teams are maybe even more engaged than they were before.” – Barbara Rubino, LADHS
Bay Area Community Health
Throughout the Population Health Learning Network, BACH has focused on providing comprehensive care for patients with diabetes. It formed the Healthy Road for Diabetes class in the first year of the program to reach patients with high A1C levels – a hallmark of uncontrolled diabetes – and in the second year, it began to offer case management for diabetic patients to work on glycemic control. While clinical outcomes for some patients improved, BACH saw a plateau in its impact. It turned to the PRAPARE screening to better understand the social determinants of health that affect its patient population.
When BACH first began administering the screening, it realized patients did not complete all the questions or fully engage with the tool. After digging deeper, staffers learned that one reason was concern that the responses would affect health insurance status (due to questions around income). Patients would also skip questions about specific measures, such as stress, domestic violence, and living conditions, due to worries about potential repercussions. Once BACH had a better understanding of patient’s concerns around the screening, staffers began discussing the tool in their group diabetes classes and reassured patients that there would be no repercussions from their answers. Staff also met with patients in one-on-one sessions to discuss their results.
“Administering the survey is challenging but it’s the easier part of the SDOH work. The hardest part is linking the patients to proper resources and following up to make sure the loop is closed, and if they need ongoing support, making sure we can provide it.” – Patient Wellness Program Manager, BACH
It took time for BACH to begin using the screening tool with patients, as it had to work with staff across teams to create a comprehensive and achievable workflow for implementation. Upon administering the PRAPARE screening and analyzing results, BACH learned about specific gaps related to social determinants of health and particularly food insecurity. Staff then began to implement tangible programmatic changes to help connect patients to social service providers. Some activities included:
- Implementation of an onsite Food Farmacy in the clinic each month
- Providing patients with food vouchers and bus passes
- Increasing awareness of behavioral health services, including behavioral health classes, for people with diabetes
- Partnering with a rideshare company to get patients to and from their appointments
Just as BACH began to consistently use the PRAPARE tool, COVID-19 hit and upended normal operations. The organization faced specific hurdles in their population health strategy, including:
- Reduced in-person visits: The pandemic has removed “warm handoffs” and personal touches with patients. It has proven more difficult online to build rapport, motivate patients, and learn about other medical or social challenges they might be facing, thus decreasing opportunities for community linkages.
- Lack of group diabetes classes: Group diabetes have been cancelled for the time being and will continue when it is safe to gather in groups, or perhaps be transitioned to virtual classes. This has limited staff opportunity to discuss the PRAPARE screening and various social services with diabetes patients in particular.
Adaptations in Light of COVID-19
“We have become creative in methods of providing care to patients.”
With the impact of COVID-19, BACH lost the convenience of talking to patients about PRAPARE and social services in their diabetes classes. As a way of adapting (and expanding) their population health work, they transitioned to reach more patients through technology solutions. BACH placed “wellness calls” to more than 27,000 adult patients in the clinic. These phone calls served a multi-pronged purpose of 1) screening for COVID-19 symptoms and offering resources for treatment if indicated, and 2) informing patients of resources for food, alternative transportation, legal guidance, and medical care options during shelter-in-place restrictions.
In addition to using phone screenings as an opportunity to provide care, BACH has continued serving patients through new, remote procedures. They are working to sustain telehealth and virtual visits with their patients to continue conversations around SDOH and care plans. Case managers are reaching out to patients to check in on their health goals and complete screenings via phone. They are currently training staff to conduct virtual visits through Epic, their electronic health record. Further, they recently launched drive-through A1C checks and walk-up blood pressure checks outdoors. BACH is also exploring the idea of offering their group diabetes classes online through a video session to continue their population health efforts in the context of COVID-19.
Both LADHS and BACH have implemented PRAPARE, increased social service referrals for their patients, and transitioned care strategies to continue making strides in the midst of the COVID-19 pandemic. Their experiences hold lessons for other community health centers who are building their SDOH capabilities and reimagining their population health strategies in the midst of an emergency response and beyond.
- Virtual patient outreach provides opportunities for new types of care. While the COVID-19 pandemic has left many employees overwhelmed and scrambling to keep up with normal operations, it has also provided new opportunities for increased virtual patient outreach. For example, BACH conducted 27,000 wellness calls, in which it offered proactive care through screening, as well as SDOH screening and linkages to help patients with care needs that might have otherwise gone unnoticed and unaddressed.
- Physically distant health and social services are possible and valuable in the pandemic. Both LADHS and BACH quickly pivoted to provide services to their patients in ways that complied with local social distancing guidelines. Their agility benefited patients who are at an increased risk of food insecurity during the pandemic. Both LADHS and BACH are also exploring telehealth options to continue offering routine care. Community health centers around the country have the opportunity to engage with telehealth and connect with patients who might not otherwise be able to come into their clinics, even after the pandemic eases.
- Linking patients with social services builds trust. BACH and LADHS’ work in screening for social needs as part of the pandemic response highlights their ability to build trust with patients and establish a baseline of care. LADHS reflected that meeting basic needs is a first step in discussing chronic medical conditions that so many patients face. When patients are not able to put food on their table or are experiencing increased stress and anxiety due to the pandemic, health centers have the responsibility to meet patients where they are and support them.
- Collaboration and knowledge sharing is more important now than ever. Both LADHS and BACH highlight the importance of sharing best practices between sites and individual departments. BACH noted that communication between its internal departments dramatically increased during its population health implementation work. Moreover, all the departments have engaged in open communication to better understand the need for social service screening and linkages to improve health outcomes. LADHS has followed up with successful sites (“success” being determined by its newly implemented SDOH data dashboards) and asked them to share their learnings with other clinics. The value of collaboration, which began before the COVID-19 crisis, has been reinforced as sites learn about providing care during a pandemic together.
“The importance of sharing with others doing the same type of work is even more important and relevant. Everyone is figuring out how to do the work in a new way.” – Barbara Rubino, LADHS