Integrating Social Care into the Delivery of Health Care Moving Upstream to Improve the Nation's Health (2019) / Chapter Skim
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6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions
6 Implementing Awareness, Adjustment, and Assistance Strategies in Health Care Delivery Settings: Challenges and Potential Solutions
Pages 137-162
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From page 137... ...
The committee, therefore, drew on the peer-reviewed and gray literature and on expert testimony to identify potential challenges to health care delivery-based activities to identify and intervene on social risk factors. This chapter's focus is on implementation barriers associated with awareness, adjustment, and assistance activities that can support social care integration.
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From page 138... ...
These challenges may include, for example, obtaining leadership support and staff buy-in, including new voices from those with expertise in social care alongside traditional health care professionals, and resolving logistical and operational issues. Health system leadership must buy in to social care integration and be willing to both innovate and prioritize social care integration (Boyce, 2014; Institute for Alternative Futures, 2012)
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From page 139... ...
Table 6-1 provides a summary of common implementation barriers and potential strategies for initiating social care integration. Establishing payments for social care integration is covered in Chapter 5.
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From page 140... ...
Challenges to Documenting Social Needs Logistical The challenges to identifying and documenting patients' social needs may include identifying a target population, selecting screening tools, designing workflows, creating staffing plans, providing appropriate training, obtaining the needed technological tools, and making rollout plans. The questions that need to be answered include • Which patients?
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From page 141... ...
IMPLEMENTATION CHALLENGES AND SOLUTIONS 141 TABLE 6-2 Potential Strategies for Documenting and Identifying Social Needs Phase Potential Challenges Strategies to Address These Challenges Logistics Which patients Learn from early adopters, assess local needs and resources, obtain and use patient feedback, use an implementation advisor Which tool Assess local needs and resources, obtain and use patient feedback Documenting Social Needs Which workflow Revise professional roles and workflows, conduct small tests of change When Revise professional roles and workflows, purposely reexamine the implementation How to administer Revise professional roles and workflows, use an implementation advisor Who will administer Revise professional roles and workflows, create new clinical teams Planning for roll out Conduct small tests of change, purposely reexamine the implementation Staffing Revise professional roles, conduct ongoing training Use of technology Promote adaptability, use quality monitoring Provider Perceived lack of Alter incentives and staff resources Do not see the need Share data with clinicians May not feel Engage patients to increase demand Identifying Social Needs comfortable Overburdened Revise professional roles and workflows, create new clinical teams May not want to change Identify and prepare clinical champions Patient Not receptive Involve patients in planning Unprepared on Prepare patients to be active participants embarrassed Unmotivated to take Explore patient barriers to action, prepare action patients to be active participants Screening type Obtain and use patient feedback Clinical relationship Develop patient-centered language to discuss screening efforts
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From page 142... ...
Social care integration may involve hiring new staff, removing staff from other activities, or adding to existing workloads. Screening conducted by non-clin ical staff (e.g., community health workers)
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From page 143... ...
Training staff to conduct social needs screening requires conducting a needs assessment of the targeted learners, developing or identifying an appropriate cur riculum, identifying appropriate educational methodologies, se lecting and training the trainers, creating an evaluation plan, and allocating funding, time, and space for the training to occur. • Do the available technological tools support social needs screening?
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From page 144... ...
. Some may think that they know the patient's situation, question the need for standardized screening, prefer an individualized approach, feel that there is inadequate evidence of the impact of managing social care to justify the effort involved in such integration, or think that atients p will not seek out social care resources even if referred (Nelson et al., 2015; Pescheny et al., 2018; Thomas et al., 2018)
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From page 145... ...
Tables 6-3, 6-4, and 6-5 list common challenges to reviewing and responding to social needs and potential strategies to address these challenges. Challenges to Reviewing Social Risk Data To successfully integrate social care into health care, processes for reviewing, analyzing, and acting on patient-reported data and communicating results across care team members must be developed and tested TABLE 6-3 Potential Strategies for Reviewing and Responding to Social Needs Phase Potential Challenges Strategies to Address These Challenges Identify a process Conduct small tests of change, promote adaptability Reviewing Social Needs Identify workflow Engage staff in planning, revise professional role and workflows Lack incentives Alter incentives, mandate change Retrieving and reviewing Conduct small tests of change results Which needs require a Involve patients in planning, learn from early response adopters, assess local needs and resources Data easy to find and Conduct small tests of change, use data experts interpret
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From page 146... ...
. Challenges to Responding to Social Needs Data Broadly speaking, practices may respond to patients' social needs by adapting care plans to account for these needs or by referring patients "internally" to a clinic social worker or care navigator, to resources provided by the clinic (e.g., food, transportation, or legal services)
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From page 147... ...
IMPLEMENTATION CHALLENGES AND SOLUTIONS 147 TABLE 6-5 Potential Strategies for External Referrals Phase Potential Challenges Strategies to Address These Challenges Logistics Workflow -- no Adapt workflows, conduct small tests of appointment made change Staff roles Clearly define team roles Knowledge of Conduct assessment of local needs and resources resources Staff Knowledge of Conduct assessment of local needs resources and resources, develop and distribute educational materials Patient Already have access Conduct assessment of local needs and resource, involve patients in planning Negative past Obtain and use patient feedback experiences Not confident in Prepare patients to be active External Referrals navigating the system participants, develop and distribute educational materials Do not believe CBOs Obtain and use patient feedback, can help develop and distribute educational materials May have already taken Obtain and use patient feedback action May only be interested Obtain and use patient feedback, in a medical solution develop and distribute educational materials Fear -- stigma, loss of Involve patients in planning, obtain and benefit, deportation use patient feedback Lack transportation Involve patients in planning, link patients to existing resources, build organizational networks Lack time Revise workflows, involve patients in planning Patients lost to follow Involve patients in planning, prepare up patients to be active participants continued NOTE: CBO = community-based organization.
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From page 148... ...
148 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE TABLE 6-5 Continued Phase Potential Challenges Strategies to Address These Challenges Technology Closing the loop Use data experts, change record systems, conduct small tests of change Data privacy Use data experts, change record systems Lack of CBO Provide local technical assistance, infrastructure capture and share local knowledge Other barriers to data Use data experts exchange Cost for social service Refine or innovate billing practices lists Clinic staff unaware of Conduct educational meetings, provide technology for referrals ongoing consultation Staff may not be able Provide ongoing consultation to access tools May lack mechanism Use data experts, provide ongoing for noting referral in consultation External Referrals patient record Partnership Establishing Build coalitions, establish formal partnerships agreements Barriers to creating Identify and prepare community and maintaining champions partnerships CBO capacity Adapt payments structures, technology, staffing, or partnerships Lack of partnership Offer training to CBO leadership experience Training and Conduct educational meetings, provide implementation ongoing consultation support needed Effective cross-sector Conduct small tests of change, promote workflow adaptability Reimbursement Refine or innovate billing practices challenges CBO financial Partner to seek alternative sources of instability funding Lack of methods Consult with data and evaluation experts for demonstrating partnership impacts
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From page 149... ...
; if the EHR does not support referral documentation, the clinic staff may use less track able work-arounds such as telephone and faxes (Craig and Calleja Lorenzo, 2014)
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From page 150... ...
. They may already access the needed service; be ineligible for certain services; feel discomfort engaging with clinic staff about non-clinical needs; have negative past experiences with such services; lack confidence in navigating such systems on their own; doubt that CBOs can help them; not be ready to take action to address a given need; fear stig matization, loss to benefits, or deportation; or lack transportation or the time to access such services (Knowles et al., 2018; Pescheny et al., 2018)
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From page 151... ...
EHR functions for listing social service agencies and documenting referrals to such agencies are emerging, but have not been tested. When a patient is referred to a CBO, ideally the medical practice and CBO would be able to communicate about this referral in real time, but chal lenges to "closing the loop" (i.e., informing the health care entity that the patient accessed the services to which they were referred)
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From page 152... ...
They may be unsure whether they will benefit from entering into such partnerships with medical practices directly or through businesses that help coordinate such efforts. For example, CBO-staffed social workers partnering with a clinic to provide biopsychosocial assessment and case manage ment as part of the interprofessional team may offer an effective intervention, but unless the practice refers with enough volume and agrees to share clinical, usage, and cost data with the CBO, it is difficult to develop a business case for the partnership, and
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From page 153... ...
. Prepare to Implement Social Care Integration Whether health care hopes to integrate with social care by documenting a single need or by screening for and acting on many needs, the efforts will be enhanced by communicating a clear and strong commitment from leadership to making this change, creating a formal implementation plan, and putting the needed infrastructure in place before implementation begins.
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From page 154... ...
Implementation Strategies Targeting Clinical Staff Many strategies may help address provider and staff integration challenges, including • Identify and support a clinical champion to oversee and advocate for social care integration, and give the champion authority and time for implementation activities. Ideally, this person will be trusted by clinical staff and an experienced EHR user (Andermann, 2018; Gold et al., 2018)
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From page 155... ...
Small tests of change can accelerate the adoption of social care integration workflows. Test and hone clinic social needs processes on a small scale, address problems, and then scale up.
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From page 156... ...
. • Provide feedback data to show medical practice staff and leadership on progress in implementing social care integration (Pescheny et al., 2018)
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From page 157... ...
. • Work with partnering agencies and organizations to identify funding structures that support social care integration; for example, some payers may require social needs screening and referrals, such as account able care organizations (Amarasingham et al., 2018; ndermann, A 2018; Bachrach et al., 2014, 2018; Crumley and Marlise, 2018)
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From page 158... ...
2018. Addressing social determinants of health through Medicaid accountable care organizations.
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2018. Adoption of social determinants of health EHR tools by community health centers.
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2016. Community health center pro vider ability to identify, treat and account for the social determinants of health: A card study.
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2018. Integrating community health workers into medical homes.
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From page 162... ...
2017. Using struc tured and unstructured data to identify patients' need for services that address the social determinants of health.
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