SDOH and Access Screening Referral Tool, Access to Care Partnership

State: OH Type: Promising Practice Year: 2019

Columbus Public Health (CPH) department is charged with assuring conditions in which people can be healthy. CPH has an annual budget of nearly $50 million and more than 450 employees. Columbus is the state capital and the 14th largest city in the U.S., with a population of nearly 900,000. Columbus continues to face health care disparities, as nearly 50,000 low-income residents remain uninsured. This is significant among minority populations, as 28% of foreign-born residents, regardless of citizenship or income, remain uninsured. Nearly 47% of CPH's client population is also uninsured.

In 2016, the Access to Care (Access) program formed a quality improvement (QI) project team and develop goals aimed at reducing the number of uninsured clients by 10%. This strategy was successful, reducing the uninsured population by more than 11.2% between 2016-2017. As a next step, the Access program sought to identify additional gaps in service, and set a goal to revise the referral process and increase referrals for health insurance by 15% and social service needs by 10%. Previously there was no set method for making referrals, but this was partially streamlined through the Social Work Scripts (Rx) program, an evidence-based social determinants of health screening tool. A paper form captures information and integrates social needs into patient care. While Social Work Rx provided a handoff for clients to receive follow up, referrals weren't consistently captured. Oftentimes, when a client is identified as uninsured, if they are willing to receive in-person help, they are directed to CPH's Resource Room to get assistance with insurance on a walk-in basis. However, enrollment help wasn't consistently provided, wait times varied, and there wasn't a process for follow up. Additional challenges with referrals included lost Social Work Rx forms, delays in turning in forms, and varying methods of delivery of the forms. To explore this, the QI project team planned a process mapping meeting in November 2017 with front-line staff from CPH's clinics. Each staff created a workflow diagram with the goal of gaining a clearer understanding of how individual referral processes work. Findings showed that referrals were dependent on individual preferences and capacity. This gave evidence to begin developing a streamlined process for referrals that protect personal information. The QI team decided to pilot the project through the Immunizations clinic, which sees the most diverse client base and highest number of referrals. As a result, an integrated screening tool was developed through the Electronic Health Record with questions that captured needs listed on the Social Work Rx card. Screening questions were printed on paper and laminated with a dry erase marker to check yes or no to each question. Questions were assessed to meet plain language guidelines and translated into the top three languages. If clients have trouble reading or filling out the form, staff will assist.

The Access and Social Work teams created referral portals in the EHR so each referral sends a notification to the appropriate program for follow up. Health insurance and primary care needs go directly to Access staff to connect and educate clients on their healthcare options. Prior to the pilot, the Access program has received 98 phone call referrals and assisted just over 1,000 walk-in clients with health insurance from January-December 2018. Since the pilot kicked off, preliminary data shows that from October-November 2018, the Access program had received 166 referrals for healthcare. 40% of the clients who were uninsured also checked yes” for at least one social need. If referral numbers in the clinic continue to average 160 per month for health insurance, the number of referrals made will be nearly 2,000 per year. If the project expands into additional clinics, and all other factors remained equal, CPH could be receiving nearly 12,000 referrals for health insurance per year. At CPH, nearly 92% of the individuals signed up for health coverage at CPH are Medicaid eligible. CPH benefits from the opportunity to bill and receive reimbursement from Medicaid as a part of increased enrollment. Next steps include identifying additional capacity to address the need. The team is exploring additional opportunities for reimbursement funding via existing models, as well as working to close the loop by exploring the use of an electronic, HIPAA compliant information exchange. This project has the potential to impact every client who walks in the doors of CPH. As the quality improvement team works to improve this process, the goal is to expand this project into all CPH clinics. 

Columbus Public Health (CPH) continues to identify opportunities that address the social determinants of health. The Access to Care program (Access program) has been working with the Neighborhood Social Work program and Office of Planning and Quality Improvement to identify streamlined processes for identifying needs and making the appropriate referrals. As a safety net provider, we at CPH understand that the majority of the clients we serve are experiencing challenges that related back to the Social Determinants of Health at some point or another. In our clinics, we do not turn people away due to their inability to pay, and we accept individuals regardless of their insurance status.

In our one-month pilot from October-November 2018, the Access program received 166 referrals for health insurance from our immunizations clinic. When comparing that data to the same time frame, but a year earlier, the Access program saw 55 individuals get referred for healthcare assistance for the department as a whole. This shows a 201% increase in the number of individuals being referred for services from only one of six clinics in the building. In the past, individuals would be referred by word of mouth at a clinic, or through the completion of a Social Work Scripts (Rx) card. This posed challenges in the response time, however, as the time between when a client filled out a Social Work Rx cards and when the appropriate program received the referral information varied. In assessing the preliminary data from the pilot, there has been a significant increase in the number of non-English speaking clients who are being referred. More than 50% of the referred clients are requesting a language other than English. This ties back to the original data that 28% of foreign-born residents in the Franklin County area, regardless of citizenship or income, remain uninsured. Because healthcare jargon and navigation of the healthcare system can be confusing, even to native-English speakers, this challenge emphasizes the importance of one-on-one conversations via the follow up process that happens when clients are referred. Every client has been called and provided the necessary information to move forward in completing a health insurance application, or has received information about healthcare resources if they are otherwise ineligible for coverage.

Initially, the pilot started out with 12 screener questions, adapted from the Social Work Rx card that was used prior to this project being implemented. Recently, after an initial assessment and debriefing of the pilot, the quality improvement project team narrowed the questions down to seven. These seven questions include the Center for Medicaid and Medicare Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Core Five Screening Tool, as well as a question for health insurance and a question for financial resources. The project team decided to keep seven questions, rather than narrowing it down to the Core Five, after the initial assessment of the data showed that the top seven questions generated enough Yes” responses to support the need to continue asking all clients. 

The overarching goal of this work is to streamline the departments screening for social determinants of health, improve the referral process and refer more individuals to assistance. Steps that were taken to implement this project were to assess the current scope of referral practices among all staff who make referrals, mainly frontline staff. The quality improvement project team also assessed options for how to streamline the referral process by eliminating the paper referrals and exploring options to digitalize the process. The beginning stages of the project relied heavily on the participation of staff from across the department. Programs included the Neighborhood Social Work team, Access to Care, Immunizations clinic, Tuberculosis Clinic, Women's Health Clinic, Alcohol and Drug Services, Sexual Health Clinic, Clinical Health Administration, Health Equity, and the Medicaid Administrative Claiming program.

After the process mapping was completed, the project team had a solid understanding of each individual process for making referrals across the department. The process mapping showed that every person who makes referrals for health insurance or social needs is completing the referral differently. Steps were ultimately taken to streamline this process, integrating the screening questions into the Electronic Health Record, which would ping”, or send a notification, to either the Access to Care program or Neighborhood Social Work team depending on the need. For health insurance, this provided an opportunity for the Access to Care program to work on educating clients on their options for health coverage and care. These conversations proved to be very successful for clients, as most were perceived to have a better understanding of their next steps after speaking with an Access to Care team member.

Several programs play a lead role in the development and ongoing maintenance of this program. Most notably, the Access to Care program, Neighborhood Social Work team, Immunizations Clinic team, Clinical Health Administration and Office of Planning and Quality Improvement. The Office of Planning and Quality Improvement facilitated the process mapping meeting, as well as the follow up meetings to help keep conversations on track. The Access to Care and Neighborhood Social Work team led the process from the beginning, coordinating meetings and providing feedback to the process along the way. The Immunizations clinic has played a role in the ongoing maintenance and tweaking of the project, as their staff have the direct contact with clients who are answering screening questions. Clinical Health Administration has been the primary contributor to the digitalization of the tool, integrating the screening questions into NextGen (the Electronic Health Record), working with the Immunizations team to identify the best timing for the questions to be asked, and training the Access to Care and Neighborhood Social Work teams on how to receive and follow up on a referral.

With the rapid increase of referrals that were recorded in the pilot phase of this project, Columbus Public Health has recognized the need to expand capacity within the Access to Care program to assist with the need. As of December 2018, about two months after the introduction of the screening tool, the number of referrals for health insurance through this screening tool have climbed to more than 220. Currently, Columbus Public Health is reassessing it's capacity to serve, with the goal of expanding the Access to Care program to include a Health Education Program Planner (HEPP). The HEPP would work to expand and maintain the referral program, working with individual clinics to roll out this tool across the department over the next 1-2 years. This position would also be responsible for managing data and developing reporting measures for each clinic, as well as coordinate follow up efforts with Access to Care interns. With the Department's limited budget to expand capacity beyond the addition of a HEPP, the Access to Care program will be partnering with the Office of Planning and Quality Improvement to obtain field placements for students interested in Access to Care. Columbus Public Health is one of five contracted Community Based Training Partners within a 5 state region for the University of Michigan Public Health Training Center (UMPHTC) through a large grant funded by HRSA. Students who are recruited through this opportunity will be managed by the Office of Planning and Quality Improvement, but will complete project-based work under the Access to Care program to assist with the rapidly growing referral process.

In public health, we understand that people who are poor and less educated have more health problems and die earlier than those who are richer and more educated. To make an impact on improving health equity and providing more patient-centered care, it is necessary to better understand and address the underlying causes of poor health. Columbus Public Health believes that to improve population health, health equity must be a priority and measures to reduce health disparities must be integrated into programming. Through this project, our goal is to make screening and referrals for social determinants of health part of the routine clinical process. Our objectives were, as stated:

  • November 2017: Identify current referral processes of front-line staff through a process mapping meeting.

  • Spring 2018: Identify the ideal referral process and work to integrate the screening questions into that referral process.

  • September 2018: Train Access to Care, Neighborhood Social Work and Immunizations staff on the new, revised referral process and pilot the process for one month.

  • October 2018 pilot: Increase the number of referrals for health insurance by 15% and social needs by 10%.

Each of these objectives were met over the period of one year. After the pilot kicked off, the Access to Care team proposed an average response time for follow up after an individual is referred through the EHR. The team suggested that two business days would be adequate for following up with a client who has been referred through the EHR in the Immunizations clinic. After the pilot ended, it was determined that the team did not have adequate capacity to reach this average response time. It was decided that one week would be the maximum that an individual who has been referred would have to wait for a follow up call would be on week. As the program grows in its capacity, the Access to Care team will reassess the length of time in which a response is feasible.

Specific performance measures that were used were the increase in referrals to health insurance and social needs programming, which go directly to the Access to Care and Neighborhood Social Work programs. Since the pilot kicked off, preliminary data shows that from October-November 2018, the Access program had received 166 referrals for healthcare. 40% of the clients who were uninsured also checked yes” for at least one social need. The pilot showed a 201% increase in the number of individuals being referred for health coverage and care services. Data was collected through the EHR from our Clinical Operations Officer and shared at check-in meetings with the quality improvement project team. In 2019, the Access to Care Program Manager will be trained to pull this data in order to provide monthly updates to department leadership and the Health Commissioners Office.

Modifications since the launch of this project have been made to make the screening tool more efficient and effective for both staff and clients. The original version of the screening tool listed thirteen questions, to match the questions asked on the original, paper-version of this screening process (Social Work Rx.) After receiving feedback from Immunizations Clinic staff in regards to how clients were reacting to the new screening process, as well as feedback from staff directly as to how it's impacted their intake process, it was decided that the screening tool be shortened. Since the pilot, the list of primary screening questions has been narrowed down to seven, with the remaining six questions listed as secondary, depending on the responses given in the initial screening. The narrowing of questions has allowed the Immunizations clinic staff to gather information more quickly and efficiently. ???????

One overarching goal of the Access to Care program in establishing this redesigned process was to shine light on the continuing need that residents have when it comes to health coverage and care. In 2017, 47% of Columbus Public Health's (CPH) clients, both adults and children, identified as uninsured. While CPH is a safety-net provider, the QI project team had the suspicion that individuals may be uninsured due to their lack of understanding or inability to navigate their options. The social determinants of health that impact one's ability to navigate systems more generally likely play a role in an individual's ability and to access affordable, quality medical coverage and care. This project has proven that individuals need additional education and guidance to successfully navigate through the convoluted healthcare system. Additionally, there is shared understanding that the social determinants of health are impacting health outcomes, and public health entities have a key role to play in mitigating those challenges.

After the success of the pilot in the Immunizations clinic, it was recommended by the Office of Planning and Quality Improvement that the QI project team expand this process into all clinics that operate under CPH. Additional money can be generated several way if this program were to be successful in the long term and this will drive sustainability efforts for the future. Staff who are participating in Medicaid Administrative Claiming can claim their time spent on this work through specific coding that will generate reimbursement for the department. Retroactive coverage for individuals who obtain Medicaid through enrollment services at CPH or who are connected to enrollment via follow up will allow the department to receive reimbursement and revenue from billing. Lastly, the department is exploring reimbursement through Medicaid Managed Care Organizations through the Community Pathways HUB Model, which provides reimbursement funding for organizations that are referring clients to address their social determinants of health. As this program and process evolves, the Access to Care program will seek to expand to manage outreach, education and additional expansion into all clinics. Phase two of this process will turn to outreach efforts into the community, connecting Columbus residents with enrollment opportunities as well. ???????

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