module #5: what is the hcdi-san caring for your health … · 2019. 2. 6. · delighted to share...

Module #5: WHAT IS THE HCDI-SAN CARING FOR YOUR HEALTH TOOL on the Social Determinants of Health? (CFYH Tool on SDoH)For more information on TCPI SANs please use this link: http://www.tcpisan.org/

http://www.tcpisan.org/

For more information on TCPI SANs please use this link: http://www.tcpisan.org/ 2

HCDI Overview• HealthCare Dynamics, International – founded and led by clinicians• 25+ years supporting CMS quality and population health programs • NICHE: Policy to Practice Strategy focused on health care delivery systems and the

quality/cost for vulnerable populations• Customized learning and action platforms focused on clinicians, patients and health care

systems

HCDI-SAN Learning Library: OverviewCFYH Tool

• The HealthCare Dynamics International (HCDI) Support and Alignment Network (SAN) is delighted to share the ‘Caring for Your Health’ Social Determinants Indicator Tool (CFYH Tool).

• HCDI-SAN developed the ‘Caring For Your Health Tool’ in response to clinician concerns regarding the social factors affecting their patient population, the impact of these factors on clinical outcomes, and the subsequent negative adjustment that can result from value-based payment model.



Learning Objectives: Caring For Your Health Social Determinants Of Health Indicator Tool (C.F.Y.H. Tool)Upon completing review of this slide-deck presentation, participant will able to understand the:

• ‘Gaps’ in care related to the SDoH• Influence of the SDoH in determining an individuals health care condition • Importance of health equity• Significance of population health management



CARING FOR YOUR HEALTHSocial Determinants Indicator Tool (CFYH Tool)The ‘Caring for Your Health’ Social Determinants Indicator Tool is both a patient level and population health management tool that:• Provides real-time opportunities to identify socio-economic factors that can

affect the patient’s clinical outcomes• Assists in stratifying patient risk• Allows for documenting patient case complexity• Aids in developing early interventions to reduce preventable hospitalizations

and ER visits• Promotes health equity



CARING FOR YOUR HEALTHSocial Determinants Indicator Tool (CFYH Tool)• This brief questionnaire is patient facing and provides real-time, up-to-date

information to the patient and clinical team. It also creates an opportunity for shared decision-making to identify patient preferences to improve the quality of their care.

• HCDI SAN provides free training and technical assistance to effectively integrate this tool into many different types of already established work flow processes.



Overview: Social Determinants of Health• SDoH also refers to the bigger set

of forces that shape the conditions of daily life of an individual.

• These forces can be social norms, culture, social practices, economic policies, developmental agendas along with political systems of any state/nation

• SDoH are considered as the root cause of our health and disease.

• Often times it is also known as the ‘cause of the cause’.



Aligning the HCDI-SAN CFYH Tool On SDoH with the TCPI Change Package and Overall Goals



Leadership commitment

• It is important to ensure practice or health system leadership is committed to improving population health

• Align initiative with key practice strategic goals• Identify a champion who will be the central point of contact• Develop an implementation timeline• Identify resources



Workflow• Determine the capacity of the Electronic Medical Record

– Is there a population health module available? YES NO– Is it presently being used? YES NO– Are present questions SDoH related? YES NO/ NA– Is the information presented being analyzed? YES NO– How often is the information reviewed? YES NO– What reports are available through the system? YES NO– Is it possible to expand the number of questions asked in YES NO

the current system?

• What is the optimum time to capture the information?– During the pre-visit ( 72 hours before the appointment YES NO– During the registration time at the office visit YES NO



Team collaborative approach

When each member works to the top of their license, provider administrative burden decreases

Administrative Staff• Ensure CFYH tool is administered

at each visit• Ensure data is reviewed and

triage for clinical staff, if needed• Provide community referrals or

resources based upon information gathered, provided, etc.

Clinical Staff• Address key areas of the SDoH

that impact clinical outcomes



HCDI-SAN Caring For Your Health Tool: Questions

• The answers you give are private and the information collected will be used to give you information about resources in your community that may help and empower you to improve your health and quality of life.

Let’s get started… In this first section, we are just going to ask for some basic information about you!

• Zip Code• First Name• Last Name• Year of Birth




Questionnaire: Please answer any of the questions listed below.

Choose 1:• Gender - Male, Female, Other• Race and Ethnicity - Black/African American, White/Caucasian,

African/Caribbean, American Indian/Alaskan Native, Asian American, Asian/Pacific Islander/Hawaiian, Other, Hispanic/Latino

• Marital Status - Married, single, divorced, widowed, • Education - did not attend High School, some High School, High School

graduate, Some College, College Graduate, Professional Certification, and Graduate School

• Health Insurance Status - Private, Medicare, Medicaid, Uninsured, Not sure




OK! Now that we have the basics covered, let’s talk about a few specific things that might be affecting your overall health.1. The food that we bought just didn’t last, and we didn’t have money to

get more. For your household in the last 12 months, was that often, sometimes, or never?

2. Do you think you might become homeless? Yes, No 3. Has any company said they would shut off services in your home?• Electric : Yes, No, Already Shut Off• Gas: Yes, No, Already Shut Off• Oil: Yes, No, Already Shut Off• Water: Yes, No, Already Shut Off




4. Has there been a time when you needed to see a doctor but could not because you did have enough money? Yes, No

5. Do you skip medicine to save money? Yes, No

6. Do you need help reading the papers your doctor gives you? Yes, No 7. Have you had to go without health care because you didn't have a way

to get there? Yes, No8. During the last four weeks, have you been actively looking for work?

Yes, No9. Do you feel lonely? often, sometimes, or never



HCDI-SAN Caring For Your Health Tool: Questions10. Do you have a problem with any of the following where you stay? • Bug infestation: Yes, No • Mold: Yes, No • Lead Paint or Pipes: Yes, No• Non-working smoke detectors: Yes, No

11. Do you need help with any of these activities? • Bathing: Yes, No• Getting Dressed: Yes, No• Preparing Meals: Yes, No• Shopping: Yes, No• Managing Money: Yes, No

12. Since the last time you were here, have you been cared for at a hospital? Yes, No



HCDI-SAN Caring For Your Health Tool: Summary

• Thank you for taking the time today to answer these important questions.

• I hope you have a great visit with your provider.

• When you checkout - remember to ask for your free, custom report, showing resources in your area that can help you! It was created specifically for you based on the answers you provided today.



HCDI-SAN CFYH Tool Goal: Health Equity

4 High Risk

Factors



HCDI-SAN CFYH Tool Goal: Health Equity• The HCDI-SAN goal is to ensure clinicians, especially those serving vulnerable

populations understand Health Equity and the importance of addressing the social determinants of health as they achieve clinical transformation to actively participate in the Quality Payment Program (QPP). We aim to support practices to:

• Address the social factors that impact clinical outcomes• Improve practice care coordination methods• Adopt population specific needs • Collect REaL data• Close the gap between communities and health care delivery systems• Improve health promotion and the prevention/ management of chronic diseases • Promote culturally and linguistically appropriate person centered care• Provide shared decision-making and enhanced access to healthcare services



Learning In Action: “Food For Thought”

• How might having data on patient SDoH affect how your office provides care?• Do you think that SDoH (i.e. food insecurity, transportation, literacy) are

common among your patients?• Think of a recent patient case in which SDoH might possibly have contributed to

a problem or a poor health outcome.• Think of a recent patient case in which SDoH might possibly have contributed to

a problem or a poor health outcome.



Community Resources: Social Determinants of Health

• Whether it’s access to food, transportation, financial services or education, addressing social determinants is a critical component of both quality of care and quality of life. Aunt Bertha is deploying this comprehensive approach, powered by technology, to help lead the way for patients in need and the people who serve them.

https://www.auntbertha.com/


https://www.auntbertha.com/

Questions?Uchenna Okoli

[email protected]

301-552-8803www.hcdi.com


mailto:[email protected]

http://www.hcdi.com/



Learning & Action Network Acronym Guide:

AAPM: Advanced Alternative Payment ModelsAPM: Alternative Payment ModelsCEHRT: Certified Electronic Health Record TechnologyCFYH Tool: ‘Caring for Your Health’ Social Determinants Indicator ToolCMS: Centers for Medicare & Medicaid Services HCDI: HealthCare Dynamics International LAN: Learning and Action Network MACRA: Medicare Access and CHIP Reauthorization ActMIPS: Merit Based Incentive Payment System PTN: Practice Transformation Network QPP: Quality Payment Program REaL Data: Race Ethnicity and Language DataSAN: Support and Alignment Network SDoH: Social Determinants of HealthTCPI: Transforming Clinical Practices Initiative


module #5: what is the hcdi-san caring for your health … · 2019. 2. 6. · delighted to share...

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