Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Sea Chen, MD: Hello, my name is Sea Chen and I'm the physician director of practice sustainability at the American Medical Association. Today we'll be discussing how a group of private practices successfully implemented a program addressing social determinants of health.
First, I'd like to introduce our guests who represent the Professional Medical Corporation, or PMC, which is a network consisting of over 200 small independent primary care and specialty medical offices, or approximately 460 independent physicians in the Flint and Genesee County communities located in Michigan. Karly Saez is the operations manager at PMC, and Dr Farhan Khan is PMC's medical director.
It's a pleasure to have you here today, Karly and Dr Khan, to discuss your experiences incorporating the social determinants of health in your practices. Before we begin our discussion, I wanted to give some background to the importance of our topic. The World Health Organization defines social determinants of health, or SDOH, as the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems that shape the conditions of daily life.
As we all know, health is more than just medical care. Social determinants of health impact practices' clinical outcomes data, practices' financial sustainability, resource allocation decisions, and the overall health of communities and the health care system. Given the move toward value-based care, expanding the health care focus to include social determinants of health is increasingly necessary to achieve improved outcomes.
So thank you for joining us, Karly and Dr Khan, and I'd like to pose the first question to you, Dr Khan. Can you tell us about what prompted you to start your efforts to address the social determinants of health, and was there a specific problem that you were trying to solve?
Farhan Khan, MD: Thank you, Dr Chen. And thank you for giving us a chance to talk about our SDOH project, and I would like to thank you, to AMA, for giving you the chance as well.
To answer your question, I think PMC physicians were aware of SDOH and its importance, especially the existence of SDOH needs in our community, which were especially worsened by the Flint water crisis. As you said, we consist of a lot of independent practices. They all have different ways of identifying SDOH needs. Some were using verbal questions, some were using self-created screens, and others were using EHR templates. It was difficult to gather information on the needs of patient community so the practices and PMC could understand what areas to address. So we needed a better way to collect, view, and analyze the need of our community.
Dr Chen: Thank you, Dr Kahn. Given all the negative impacts of the Flint water crisis, it's really uplifting to see the independent physician community really spurred onto action in order to make that positive impact for their patients and the citizens in the PMC community at large. Karly, could you share your perspectives on this?
Karly Saez: Sure. And thank you Dr Chen, and the AMA for having us. Like Dr Khan mentioned, I think just first acknowledging the existence and importance of social determinants of health was key. We had many practices doing their own approach to collecting SDOH information, if they were collecting it at all. The physicians knew the SDOH needs of our community, but it made it very difficult to put the needs into numbers. In order to have actionable outcomes, we needed to have those numbers.
But that change didn't happen overnight, we needed to help practices develop processes to screen patients. And one of the ways in doing that was creating a single screening method that could be used across all of our practices, which would help us as an organization to collect the information. We also had to really support our practices with our practice transformation coaches in assisting them to work the SDOH survey into their workflow. Given that all of our practices are independent, and they have varying degrees and levels of staff and staff experience, we had to make that a very individualized process for the practices.
Just making sure that it was doable for their practice, whether that was helping them build it into their EHR templates, or it was helping them print copies to provide to patients or helping to educate their staff in having that comfort of asking sometimes very sensitive questions to already health care-skeptical patient populations. So again, just supporting practices with how to assist their patients as well.
That was some of the negative feedback that we got in the beginning was the hesitation in asking such sensitive questions, is how to then help patients who had identified needs. But luckily, in 2016, our efforts were catapulted when the Michigan Department of Health and Human Services announced the Michigan SIM model or State Innovation Model. And this was a three-year grant that included numerous requirements, some being embedded care management with nurses and social workers, connection to the Michigan Health Information Exchange, or MiHIN, and also inclusion of a standardized SDOH screen.
So the goal of this program, which continues today as our goal in PMC for care management, was identifying patients' SDOH needs so that they could be addressed. But then also PMC and the leadership wanted to take it a step further so that we could consolidate the information to better identify the needs of our community, which we shared that information with our community leadership and community agency partnerships to really help guide and support our direction.
Dr Chen: Thanks so much, Karly. Implementing any successful program, I think that engaging key stakeholders is critical as well. Dr Khan, who do you think were the key partners in your mind?
Dr Khan: Our partner was our practices, like PMC board and leadership decide after the SIM project that we should provide our care management to all our PMC practices free of charge. Initially we garnered few physicians to adapt and participate in this intervention, so that we were able to eventually scale it to rest of the practices.
We also had community representation and partnership, like Greater Flint Coalition. That's a big organization where most of the health care entities participate in this in our area. That was our start for this project.
Dr Chen: Great. Thanks so much. Karly, from your lens, were there any other relationships that you all cultivated during this process?
Saez: Yeah, I think from an operations manager point of view, I cannot give Dr Khan and our leadership enough credit for helping us get this off the ground with being able to screen our patients for SDOH. We really capitalized on the physician champions in our organization or those physicians who were early adopters of the SDOH screen, and how they saw it working to transform the lives of the patients. And using those physicians to have conversations with physicians who were more resistant or had those more resistant practices.
We also had to really do what we could to remove barriers. So utilizing the care managers, and we'll talk a little bit on this as well, but the social needs coordinators, just really helping to take them, the individual who was serving the practice, as Dr Khan, we provided care management free of charge to practices. And meeting the practices in person and embedding those care managers in some of the larger and high-need practices. And they were good representations by working at the top of their licensure, getting patients engaged and connected to their medical home, showing them both the clinical value to their practice and the nonclinical value of connecting those individuals with community agencies to ensure that they receive the support that they needed.
As well, our practice transformation consultants and the PMC leadership helped the practice to see the financial value of SDOH in the engagement with care management through billing the care management codes to certain health plans. As well, having the technology partners with connecting our EHR vendors and the statewide HIEs. Those were just certainly some of the partnerships that we started to build back in 2016 and 2017, and we still work to strengthen on a very regular basis, sometimes weekly basis, today.
Dr Chen: That's great. I know, Karly, you mentioned the social determinants of health screening, which is obviously critical in assessing the needs of the patients. Could you expand on that a bit more about what that meant for PMC?
Saez: Sure. What was really important to PMC in the beginning is that we didn't reinvent the wheel, and also making sure that we used a validated screening tool. So our community, our health care community as a whole, including PMC, took a look at the different options that were available at the time in terms of social determinants of health screening.
And the one that we selected was health leads. Just given its very straightforward in nature, the ability for the care managers and the practice staff to quickly assess the results of the screen and take action. But we did modify it slightly to include questions related to our community, namely at the time and still occurring, issues from the Flint water crisis. That screen includes numerous domains, including food, education and training, income, cost issues related to health care, physical and mental limits, creating limits to activities of daily living, taking care of family and friends, housing, home safety, transportation, utilities, mental health, as well as access to clean water.
One question that really stood out to the survey, when we were looking at different surveys, is the final question on the survey was, “Are any of your needs urgent?” So that if that were the case, the physician and the staff would know, “I need to address this right now.” And that was pivotal in helping to get practices engaged with our care management staff to not put the burden or the responsibility only on maybe that 1 or 2 different staff members in a very small independent physician office, so that we could support that patient with obtaining services or addressing their needs right away.
Dr Chen: Dr Khan, what are your thoughts?
Dr Khan: I think through the screening, I tell you, the practicing physician, the patients were able to tell us about their need that they would've never thought to bring up in a physician office. Things like housing and utility bills, food insecurity.
I give you example. We just ended our winter season, and a lot of patients identified the need of assistance with a utility bill. In winter, keeping the heat on is a basic need, especially in Michigan. So we were able to connect them to the resources where they can get some help. We were never able to learn about issues like these if we didn't do the screening.
Dr Chen: That's wonderful. I think as practicing physicians, we oftentimes know in the background that we need to pay attention to these things, but I think the screening and dedicated program really put that into context. Thank you for giving us those examples.
I'd like to switch gears a little bit and do a deeper dive into some of the details, especially in your case study, which for our listeners we'll link in the episode description. But in that case study you mentioned a SDOH Z code key that was developed, which helped your practices become familiar with and utilize these Z codes to submit to health plans for when SDOH needs were identified and addressed. Karly, could you share with our listeners why this was so important?
Saez: Sure. Many of the health plans are now recognizing the Z codes, which are a set of social determinants or social-related diagnosis codes in the diagnosis set. So once the health plans are recognizing that a little bit further, there are some additional incentive opportunities out there which are really important to our independent primary care practices. So wanting to utilize our knowledge from our practice transformation team and educating the practices about using these Z codes, and how they can be utilized in information sharing. So it's not only the incentives that are available to the physicians, but also sharing that information with the health plan is very important, as we hope that it would shape their approaches in their internal care management teams, as well as some of the programs that they create to support our member population.
In taking this entire set of Z codes that are available to the physicians to use, it can be incredibly overwhelming. And not only that, but knowing exactly which code to use for which SDOH screen domain made it even more overwhelming. So what we did is that we took that list and we consolidated them into a single-page document and we linked each major Z code to a domain on the SDOH survey, and that way we provided the practices with the document to compliment the SDOH screen itself. So that way, when the patient turned in or the MA (medical assistant) collected some information on a patient that identified they had a housing need, they can make a more informed choice on a much smaller set of Z codes to use and to bill to the health plan for that particular patient.
It also just continued to support the practices in how we could assist their patients with these SDOH needs through care management and community referrals. Many times the staff members would see that a patient had a certain SDOH domain identified as a need on the survey, and they would know, in those cases, they just didn't feel comfortable with providing that assistance so that they could immediately reach out to our care management team and our social needs coordinators to provide assistance to that patient.
And then we could also utilize that information, again, to submit to the health plan so the health plan is aware of the social needs of our patient population. And in doing so, hopefully we could get more needs and more resources brought to the Genesee County community.
Dr Chen: Thanks so much. Dr Khan, what were the implications of this SDOH Z code key for your perspective?
Dr Khan: It was important to have simplified resource for all the different practices to reference. And by using the Z code there were more and more incentives given to the practice from the health plans when they screened for SDOH and provided care management to their patient population.
Dr Chen: I'm sure that getting this really important program off the ground wasn't easy. Dr Khan, what were some of the hurdles that you felt needed to be overcome to do that?
Dr Khan: Well, there were few. As a medical actor and leader of this organization, that's my job. And we see an issue to allocate resources and to come up or put heads together to see how to overcome those.
I'll start with what we need to work on, closing the loop. This means ensuring that when a need is identified by a patient that they're actually receiving the resources we connect them to. The care management team should receive an update on each step, until the need is actually met. Another issue was timeliness. We're trying to decrease the lag from when the patient identifies the need to when the social need coordinator connects them to an appropriate resource.
Third thing is we need recognition from health plans that the information is being submitted either to MiHIN or Z codes, and ensuring that they utilize the information in some way. We need to increase engagement with some physicians by providing them education on changes in the workflow. And finally, financial support from health plans for SDOH and care management integration.
Dr Chen: Thank you, Dr Khan. Karly, from your end, what were some of the obstacles that you faced?
Saez: Probably patient engagement was one of the first hurdles that we had to overcome. Initially, we did hear from some of our practices that patients were wondering why we were asking them such nonclinical questions, and if we were asking those questions, what we could do about their needs? So just making sure that we were educating the patient and helping to coach the practice in how to have those conversations with the patient was very important.
Also, the physician education and physician engagement. Some of the physicians were resistant in asking those SDOH-based questions and almost feeling liable that if they knew about that issue and they didn't solve it, that they would be liable. And just helping those physicians, again, understand how an individual's nonclinical needs can impact their clinical outcomes. And we really worked with this by, again, employing our care managers. And then later, in the past year or two, we have hired social needs coordinators. These individuals are community health workers, licensed practical nurses and certified medical assistants, and they have the background and experience with assisting patients with their social needs, ultimately helping them to close the loop as Dr Kahn mentioned.
That was one of the hurdles that we still see, is after we engage with the patient and our social needs coordinators engage with the patient, how do we help to connect them to the community agency and follow that through to resolution? Because it's one thing to recognize a patient's need, it's another thing to connect them to a community resource. But it's the most important thing when we know and we can follow up in a month or two that that patient did receive food, they did receive help with their utility bill, and they now have housing. That is the most important thing and the biggest value that we can bring to the organization and our community.
Dr Chen: Thank you so much for sharing your experience. It's very valuable to see what sort of pain points that you all have had and how you guys have overcome that, so thank you so much for that.
At this point our listeners are probably really interested in hearing about the impacts of all your efforts so far. Karly, could you give us some results of your program?
Saez: Sure. Since our data collection efforts began in 2017, PMC has collected over 20,000 screens, completed across all of our PMC practice and patient populations. And just to put that into perspective, PMC has about 100 to 110 attributed lives to us on an annual basis. So what we have seen from those completed 20,000 screens are definitely demonstrated lots of needs in the food, transportation, and housing domains, but especially the mental health domains, which is surprising but also not so surprising.
And 1 thing that we also heard related to the mental health results that we are seeing, is surprisingly our pediatricians are seeing some relatively higher numbers than expected of mental health. Again, not surprising, but it gives us quantifiable data to support and justify more needs and services in our communities. Before it was just kind of assumed and known that we had a lot of social needs in our communities, but having this information in discreet form provided us some data that we could give to our community agency leadership, which in turn assisted their own request for internal funding and grant funding in the community, as we were able to demonstrate that there was a continued need as their organizations were already at full capacity.
Also, having these results really helped our community partnerships. Again, food was a very high-need domain in our community, and we, again, had quantifiable information to show the high needs across our population. And we're lucky enough in Genesee County to have the Hurley Food FARMacy, which is a food bank that provides food prescriptions to our community members. And given the increased needs of our community, we met with their leadership on a very regular basis. And we were trying to think of collaborative ways to not only provide our patients with food prescriptions so that they would go to the Hurley Food Pharmacy, pick out the food that they needed, but also a lot of times we have a registered dietician on our care management staff, and many times they would have identified needs at that face-to-face visit with our dietician. And so in creating that collaboration, the Hurley Food Pharmacy provided our office with bags of non-perishable foods that we could give to patients on the spot.
We also have continuing high needs in mental health. Again, just supporting our ongoing efforts, and it really helps to drive our care management matrix in how we build our team. So with those lots of high mental health needs, we built our team up with behavioral health counselors. And those behavioral health counselors are providing one-on-one counseling with patients, which is phenomenal because that way they have no out-of-pocket costs. There's no limits to how many services they can receive, which is something that's difficult in our community given the lack of adequate counselors that we have that maybe accept every insurance out there that our patients have.
Dr Chen: Thank you so much. Dr Khan, from your perspective, what have you seen in terms of results?
Dr Khan: During the program, we saw 15% decrease in ED utilization, one of the lowest ED utilization rates. It was initially demonstrated with managed Medicaid, but then later we've seen that results in our line of business. And this low utilization continues until now.
Cost of care, which is becoming the more important things every day, with SIM there was a 12% decrease in cost of care. We did another project, transformation project, we were able to decrease the cost of care by 220 PMPM, and average decrease was 164 PMPM. So these were some of our results, clinical and financial results, from these projects.
Dr Chen: That's so wonderful. I mean, it seems like your program has really been impactful for both the community, as well as from a practice standpoint. As a final question for both of you, is there anything else you would like to add that you would like to tell our listeners?
Saez: Yeah, I think just find an SDOH screen that works for your practice and educate your staff, because it is, in most cases, the staff who are either going to be giving the survey to patients or fielding the questions that they get from patients as the patients are completing the survey.
And then taking it from there and seeing what the other needs of their community are from other independent offices, maybe the hospitals in your area, or taking a look at the community agencies and what their leadership looks like and if they're willing to work with you. Because in many cases, especially for our larger independent practices, where they had a lot of needs and not a whole lot of support within the practice, is that the community agencies already saw a lot of our patients coming through their agency. So that it almost made it easier to create that collaboration and bring someone from the community agency regularly to their practice. In many cases, by building these relationships, it made it much easier for the practice in the long run by having those supports come to the practice, instead of the patients having to go to that community agency.
Dr Khan: And I would, again, talk about behavioral or mental health in our community, because that is becoming 1 of the biggest issues and that's where we see that more and more needs are marked by the patient.
And just to give you background of our area that where we are doing this project. In Genesee County, which is our major county, 40% of the people live in poverty. Around 65% of the Flint children live below the poverty line; $30,000 is the median household income in Flint; 90% of the Flint children are eligible for free reduced-price lunches. About mental health, we have 23.7% of Genesee County adults report that they receive insufficient social and emotional support. It's a big challenge.
Dr Chen: I think you've really underlined well the importance of practice transformation when addressing SDOH. Thank you so much to both of you.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
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