Assessing patients one by one for social determinants of health (SDOH) such as housing and food access is an important yet often high-touch process conducted by health center staff. So what might a lower touch approach to these vital screenings look like? Northeast Valley Health Corporation (NEVHC) explored innovative solutions to evaluate the specific needs of its 80,000+ patients throughout Los Angeles County. We hear from Debra Rosen and Alejandra Mata of NEVHC about their exciting and ongoing journey in digitizing the patient screening process. They share how integrating different tools on a familiar platform can better identify specific patient population needs. It also allows them to offer pertinent community resources more widely while improving their quality of service at the point of care.
Listen and subscribe to the CCI Health Pilots podcast on Apple Podcasts, Spotify, and elsewhere. Below is a transcript of the episode, edited for readability.
Episode Teaser / Debra Rosen (guest):
Ultimately, our goal is to screen all of our patients for social determinants. And again, we have a large number of patients. So how are we going to move from this high touch approach to a lower touch approach? And our solution was to work with One Degree – which is our digital platform for social services – and to actually digitize the PRAPARE tool. This new digital process was really an extension of the work that we already had with One Degree and being able to work with One Degree to send out the PRAPARE assessment through a text message. And the fact that through a low touch process, they’ll still be able to identify resources for themselves is really, I think, a great innovation and we’re really excited about the spread of this work.
Jessica Ortiz (CCI, host):
Hi everyone. I’m Jessica Ortiz with the Center for Care Innovations. And today, we’re talking about one of the exciting projects that Northeast Valley Health Corporation has been working on for the past year. And really, they’ve been dreaming up this solution over the past five years. Our hope is that by sharing the highs and lows of this digital health solution, safety net organizations can apply the lessons learned to their own challenges. I’m here with Debra Rosen and Alejandra Mata, member of our Tech Hub learning network, which is comprised of 14 tech-forward California based community health centers, clinic coalitions, and primary care departments and county health systems that are working to accelerate the adoption of innovative technologies. We partner with our Tech Hub members to vet, pilot, evaluate and spread innovative digital health solutions, serving Medicaid markets and historically under-invested communities. And we are really excited to bring you this story today. Debra, we can start with you. Can you introduce yourself to the listeners and share a little bit about your organization?
Debra Rosen:
Sure, happy to. Thank you, Jessica. My name is Debbie Rosen and I work for Northeast Valley Health Corporation (NEVHC). We’re a federally qualified health center in the north area of Los Angeles County. We’re pretty large — 17 licensed health centers serving over 80,000 patients. And I have been working at Northeast Valley for 34 years. So my title is director of quality, health equity, and innovation at Northeast Valley Health Corporation.
Jessica Ortiz:
Great, welcome Deb. And Alejandra?
Alejandra Mata (guest):
Hello everyone. My name is Alejandra Mata. I am the associate director of health equity at Northeast Valley Health Corporation (NEVHC). Just some large programs that I oversee at Northeast Valley would be our chronic disease programs, our programs related to health education, and patient navigation services.
Jessica Ortiz:
Great. We’re so excited to just dive right into this. Tell us about your project. How did you get started?
Debra Rosen:
Well, I’d love to. So this has been really exciting for us at Northeast Valley. We started to screen for social determinants of health (SDOH) around 2017. And our philosophy here, it’s really important that we screen our patients for social determinants, but not just collect the data. What our goal is: To assess our patients for where they are, what their needs are, but also provide resources, provide support to our patients. And what that means then is that it’s a fairly high-touch process. It’s generally one to one, either in person, sometimes on the telephone and sometimes through tablets, but on a one-to-one basis, we’re assessing using the PRAPARE tool (Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences) for social determinants. And then based on the patient’s responses, we use a product called One Degree to provide digital resources for that patient based on what their needs are. And so, although a great system, it turns out that it is very high touch and we screen only about 1,200 patients a year. So with the population of 80,000, we really needed to come up with a solution that was a bit lower touch so we were able to spread both the screening and the assessment of social determinants, but also making sure that we’re providing resources to our patients and not just collecting the data.
Jessica Ortiz:
So Debra, when you are talking about high touch, are you talking about the staff that are required to support this process?
Debra Rosen:
Yeah, that’s a really good question. So exactly. It takes an individual on one to one basis with a staff person, and we have a variety of staff that do this. We have patient navigators, some health educators through various projects. We have individuals that are trained. And as I said to do this in-person, always one-on-one, but telephone, in-person or through a tablet. But it is a one to one high touch process, so we assess and then we provide resources through One Degree.
Jessica Ortiz:
Great. So it seems that you were trying to solve the problem of screening for social determinants of health (SDOH), realized that there was a challenge with having too much staff time to put into this process. And so what far in this evolution of this project has been the highlight of moving this work forward?
Debra Rosen:
Well, there’s been a lot of highlights, so we really wanted to come up with a low touch solution. Ultimately, our goal is to screen all of our patients for social determinants. And again, we have a large number of patients. So how are we going to move from this high touch approach to a lower touch approach? And our solution was to work with One Degree, which is our digital platform – for social services – and to actually digitize the PRAPARE tool. So we send it out through a text message to our patients and they answer it on their phone or tablet or computer, and based on their answers, resources populate from One Degree that are appropriate for that patient. The patient can then choose resources, and the most exciting thing is that all of the data interfaces back into NextGen, I’m pretty excited about that.
NextGen is our EHR (electronic health record), of course, but what interfaces back is not only their answers to the PRAPARE tool that interfaces to a template in NextGen, but also what resources they chose interface to a template that we’ve developed. And so during the visit with the provider or with the navigator following up, we not only know what their social determinants are, but what resources they’ve chosen so that we can help follow up with that patient.
Jessica Ortiz:
That’s amazing. That’s so much rich data to be able to improve care for people and to see are people actually using those resources too, is really incredibly helpful. I’m curious about your process of deciding on going with the PRAPARE tool or One Degree. And how did you land there? Was there a vetting process? How did you figure that out initially?
Debra Rosen:
Well, so a number of things. So the PRAPARE tool is supported by the National Association of Community Health Centers (NACHC), and that is the tool that we started to utilize in 2017. And we did tweak it a little bit and we’re continuing to iterate. So now our electronic health record, NextGen, has a supported PRAPARE tool. I’m going to just add some important information here because now what we’re able to do is automate the ICD-10 codes, the diagnostic codes that are associated with that social determinant of health. And so when the patient answers or anyone answers that PRAPARE tool and it interfaces into the template, the corresponding ICD-10 diagnosis populates in the electronic health record (EHR) automatically. And so that is really, really exciting, and we know that both our health plans and the state of California really want the data on what those diagnoses are in the electronic health record. And it also of course then helps the provider and the care team with that patient when they’re seeing the patient.
Debra Rosen:
So we learned about One Degree a number of years ago – actually, through the Center of Care Innovations (CCI) – and this is a digital tool to identify community resources in the area. We knew that they had already populated resources in Los Angeles County. We also knew that, well, they’re a nonprofit organization and their mission really aligned with Northeast Valley, so we were really excited to start to work with them. We’ve now been working with them for many years, I believe about five years. And again, we used One Degree in that high-touch method – we would help assign our patients up with One Degree and help choose resources with them and send those resources either by email, by text, or even the “old fashioned way” by printing out a piece of paper.
Debra Rosen:
And so this is really an extension. This new digital process was really an extension of the work that we already had with One Degree and being able to work with One Degree to send out the PRAPARE assessment through a text message. And that’s really, again, very, very exciting. And the fact that through a low touch process, they’ll still be able to identify resources for themselves is really, I think, a great innovation and we’re really excited about the spread of this work.
Jessica Ortiz:
Yeah, that’s really exciting, Debra. Not only is it creating lower touch on your end at Northeast Valley, but there’s been a lot that has been said around how easy it is to send text messages and how patients tend to like to receive text messages. It makes things more simple: “one click” is the key term that’s been going around for all of these technical innovations for patient engagement. Going back to the recommendations that you provide to patients through this process and through these tools, can you give an example of recommendations that are tailored to patients, and are these recommendations based on zip code and different demographics of the patient? How do those details work out?
Debra Rosen:
Thank you. So yes, that’s a great question. They are definitely based on the responses the patient provides in the PRAPARE tool. So for example, if they screen positively for food insecurity, then we have identified, we’ve actually worked with One Degree to tag resources that will mitigate or support food insecurity and provide resources to patients and those would include food pantries, food distribution sites, even educational programs for the individual. And they are in LA County. I would love to say that we do get the zip code from the patient. Sometimes they’re a little bit farther out than we would like, and we’re continuing to iterate on this process so that the resources are really very close to where that patient lives, and that’s really important for accessing those resources.
Jessica Ortiz:
And can you share an example of how you’re using the data on the clinical side for clinical decision-making and how that’s being implemented into your workflows?
Debra Rosen:
Absolutely. So we use the data in a variety of ways. We use it on the individual basis at point of care, and I’ll talk about that in a minute. We also use it on a population level. And in terms of population, we’re able to identify all of our patients, for example, who identified as having food insecurity, and then we can reach out to the entire population that identified for that and provide additional resources.
We also use it even more globally than that in terms of identifying needs, where there are a lack of resources. So either within Northeast Valley, do we need to build up additional resources or in the community? So we have a number of different levels that we use the data. In terms of the individual level, this is really important where the provider is now more easily aware that the patient might be experiencing food insecurity, maybe homelessness, maybe difficulty with transportation. So they’re referring them to a specialist, but we see that that patient has some challenges with transportation. And so that provider and care team are able to connect that patients to resources right there and then to be able to get to that specialty visit. So this is really important at point of care.
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Jessica Ortiz:
Thanks, Debra. And I want to invite Alejandra, if you have anything to add so far that has been exciting about the solution that you are implementing.
Alejandra Mata:
Thank you, Jessica. Yes, I would love to highlight that within our EHR, we are able to see the status of the resources that the patient selects. Since they interface over into our EHR, we can see if the patient has marked this resource as utilized, planning to utilize, or if they prefer to no longer utilize this resource. If we see that a patient might have this as a plan to utilize, we’re able to see that status and we’re able to assist the patient in getting connected to that resource, since our primary goal is to make sure that our patients are actually utilizing these community resources easily.
Jessica Ortiz:
Thank you, Alejandra. And so thank you for sharing some of the key results, highlights so far of the project. Could you share with listeners some of the challenges associated with this project and implementation that you’ve come across so far?
Debra Rosen:
So one of the challenges, we want to make sure that when we send this text message, our patients are actually completing the PRAPARE tool and utilizing and choosing resources that are appropriate for them. So we are keeping track, we send out the PRAPARE to a patient. We send out the PRAPARE tool and we have a tracking tool to see how long it took for the patient to respond if they responded and if they chose resources.
Debra Rosen:
So we’re really trying to learn as much as we can and we’re trying to figure out, “Well, what are ways that we can increase the likelihood that our patients will respond to this text message?” Our patients really do like text messages. It’s the best way we have found to communicate with our patients, but this is a little bit broader. We’re asking them to answer a questionnaire through that text message. So not all of our patients are doing that and we know that, so we’re trying to learn ways on what we can do to increase the likelihood that they will respond. And I’m going to pass it over to Alejandra share some of the interventions that we’re using to increase that likelihood and have more patients respond digitally.
Alejandra Mata:
Thank you, Debbie. So as we mentioned, we are tracking when we send out the digital PRAPARE tool. We wait about two or three days to allow the patient enough time to answer this independently. And if we notice that they have not completed the PRAPARE assessment, we go ahead and give the patient a call, see if they needed any assistance completing the tool. And if they say “yes,” we can answer the questions one on one while having the patient on the phone through One Degree, and those responses will go ahead then and interface back into our EHR.
Debra Rosen:
We are also trying various interventions to, again, increase the likelihood that patients will respond digitally. So a couple of things that we’re doing is number one, we’re wanting to test on many different populations. So far, it’s still been our high risk population, and we’re really looking to test it on maybe a younger population and seeing if they’re more likely to respond to the PRAPARE tool individually in a low touch manner, so that’s one of the ideas that we’ve got. In addition to that, we are considering things like sending a text message even before they received the PRAPARE text message. That way, knowing it’s coming from Northeast Valley, that this is something important for you to answer, but that we hope that you do. And then also if they don’t respond to text message afterwards, asking if they need any additional assistance. So those are our ideals that we’re going to be implementing to see if we can increase the numbers.
Jessica Ortiz:
Thank you for sharing about some of the challenges that you’re facing and what you’re doing to try and overcome those challenges. This also leads me to think about the initiatives that are happening at the state level in California, and really this need for payers to get SDOH data. And I’m just wondering from your perspective at Northeast Valley and what you’re doing with One Degree and the PRAPARE tool, how do you feel like this supports your capacity to meet the payers’ data needs?
Debra Rosen:
Once the patient answers the PRAPARE tool, once again, the SDOH ICD-10 codes, those are the diagnostic codes, are documented in our electronic health record. Now what’s interesting is that since this is done digitally, there’s no one then to send that encounter. And I will say that once the patient answers the PRAPARE tool digitally, it creates an encounter in NextGen. So you can see on our history toolbar that the patient actually answered that questionnaire, but it will sit there because then nobody is forwarding that to our health plans and therefore the state.
Debra Rosen:
And so as a part of this work, which we’re almost ready to implement, we have now the need to add a CPT code, so that’s a procedure code – to submit it to our health plans and therefore the state. So not only is it going to be automatically placed into the medical record for clinical use at point of care, the data will be submitted automatically to the health plans and the state for use that they also want. They want to know of course what social determinants are affecting our patients at Northeast Valley and throughout the state, because they’re looking at this broader picture of risk stratification around social determinants of health, which at Northeast Valley, we’re doing a lot of work around in that we are actually assigning risk tiers to the PRAPARE tool. So once they answer those questions, they will be assigned a score and then a risk tier, and then we can stratify those patients and provide them with the support they need. Again, the higher risk patients get high touch support, the lower risk patients, lower touch support.
Jessica Ortiz:
So Debra, you’re just solving all of our problems at Northeast Valley, right?
Debra Rosen:
One step at a time. I tell you, it’s really a journey. We have lots of visions, lots of plans, lots of dreams, but it takes persistence because these changes do not happen overnight. They take a lot of work and a lot of people and a lot of steps to make it happen, but we’re really excited about the journey.
Jessica Ortiz:
I’m curious, you’ve done amazing work, and I would love if you could share with listeners, what resources have you been using and engaging with to help you think through this process, to help move this work forward? Just any resources that you can think of that others can tap into to do work as innovative as you are at Northeast Valley.
Debra Rosen:
Well, thank you, Jessica. I will say that we learned from others. It was over five years ago where we heard from another health center about a high touch and a low touch approach to social determinants. And with that, it was like a light bulb. Well, we know that we need various approaches to accomplish what we want to, which really is universal screening of social determinants. So we have, again as I shared, a high touch approach, we have to figure out what we can do to spread that in a low touch approach. So I learned that from another health center and of course, we take what we learn and we apply it here at Northeast Valley. So we have that vision and then working with our vendors, One Degree and we have an amazing IT staff here at Northeast valley that have been really involved from day one and really support this work, but really sharing our vision with them and working together with this team to figure out, “Well, what are the next steps to make it happen?” And that’s where your work that we mentioned, so just that technical piece has been within the last year.
Jessica Ortiz:
Is there any last advice you would give for other organizations that are looking to implement similar screening, integration, community resource tools and closing the loop as you all have created that process? Any roadblocks that you feel like, “Hey, think about this in advance before you engage in this work”?
Debra Rosen:
There are always roadblocks. I think that, again, persistence is really the key. I will share that it took us a number of years to identify funds to do this. We didn’t give up, and it didn’t fit the vision of everyone that we looked to fund. And we finally identified resources and we’re really excited about that. And I think that if this is a vision of your organization, you need to keep at it and find those resources that will help you implement these new ideas, new innovations. I will also say that the technical pieces are never easy, the vision is easy, but making it work is not always so easy. So identifying the right partners, we did have to add on a third partner to work and implement the interface, which is working quite well, but that wasn’t so easy initially, and so that’s something that we had to find additional resources. So I think working with a team that really shares the vision and persistence and finding those resources to make sure that your project is funded and continues for sustainability.
Jessica Ortiz:
Thanks, Debra. So as we close here, I’d love to hear what’s next for this project and innovation work. What are you really excited about?
Debra Rosen:
We’re really excited about the next steps here. I already shared that we’re able to send that text message out to an individual patient, which is great, but what we really to do is expand that to a group of patients or a population of patients. So we have the opportunity to send it out to, for example, all diabetic patients who are coming in the next couple days or send it out to patients who are coming in with their young children, maybe zero to three, for their well-child exam in the next couple days. And with that, we can send it to a group of patients all at once, get those results in for social determinants. And then the provider will be able to see that data at their visit. And so that’s our next goal is to identify those groups of patients that we want to reach out to.
Jessica Ortiz:
Great. That’s really exciting, and I look forward to hearing how that goes, and you’re a Tech Hub member so we’ll continue to keep in touch and hear what’s going on with that project. I want to thank you so much, Debra and Alejandra, for joining us, sharing your experience and expertise. You are valued members of this learning community, so thank you very much.
Debra Rosen:
And thank you so much for having us. It’s really fun to share all of our work, all of our innovations, and we look forward to the next time.
Alejandra Mata:
Yes. Thank you so much for having us.
