Professional Medical Corporation, a network of primary care and specialty medical offices around Flint, Michigan, deployed specialized screenings for social determinants of health (SDOH) to identify their patients’ needs and some of the common obstacles they faced. The medical offices and their community partners used information from the screenings to guide their patients toward essential resources. The program demonstrated a reduction in cost of care and emergency department utilization.
A water crisis and ongoing economic hardships have plagued Flint, Michigan in recent years and the city now contends with poverty rates more than three times the national average.1 It's a far cry from a community known in the late 19th and early 20th centuries as “Vehicle City”—a leading center in automotive design and manufacturing. Residents have developed long-term health issues and maintained a distrust of the health system. The ongoing struggle to address the community's social determinants of health (SDOH) has meant community members are at higher risk for developing or worsening chronic health conditions. Professional Medical Corporation (PMC), a network of more than 200 small, independent primary care and specialty medical offices in Flint, faced significant challenges and demands to improve population health as they continued to manage heavy day-to-day patient loads. Any attempt to add SDOH screening and potential needs triage to their existing workflows would require a streamlined and supportive approach to social health factors.
Developing the Intervention
PMC physicians have long recognized the ways social determinants of health affect how a patient might develop a chronic condition, or worsen an existing one. Identifying SDOH needs was a top priority, so PMC worked with local partners, including local physician-hospital and community organizations, to develop a streamlined screening tool for SDOH. They modeled theirs on an existing tool, HealthLeads, and added a question about access to clean water. PMC used practice consultants, members of PMC's health care transformation team that serve the practices face-to-face to assist with provider education on government and health plan programs, implementing best practice processes and activities, and generally helping them thrive as an independent office. The consultants shared the screening tool with team members and leadership at each practice. They communicated the importance of screening, which included asking, identifying, and acknowledging that the patient had social needs that influence their clinical needs and outcomes—and later offered additional team members and support to address those needs. They helped the practices incorporate the screening into their current workflows, implementing paper forms, or by adding the screening to their electronic health record (EHR) templates. The types of best practices ranged widely, such as partnering with EHR vendors to build the screening tool into their platform, enabling patients to complete the paper screening as part of a welcome packet, or ensuring members of the clinical team felt comfortable and well-versed asking such questions.
Beginning in 2017, PMC partnered with the Greater Flint Health Coalition (GFHC), a collective impact organization with wide representation from local support agencies, physician organizations like PMC, physician-hospital organizations, hospitals, and business leaders that coordinate activities and share best practices to improve the community's health. As part of this relationship, PMC shared their SDOH activities and processes, as well as initial findings. The leadership from the GFHC created connections and opportunities for PMC's practices to capitalize on supportive community partnerships, allowing the medical offices to quickly identify and triage patient needs using the GFHC-supported Mid-Michigan Community Health Access Program (CHAP), which provides in-home services and visits.
Additionally, PMC created formal agreements with the GFHC to deploy nurses and other health care workers such as Social Needs Coordinators (SNCs). These coordinators travel among all PMC practices, gathering and documenting SDOH screenings and results in a centralized EHR care management database. The SNCs also assist in triaging of needs by initiating and tracking community agency referrals to ensure the patient's needs were met, and these efforts help the practice's administrative teams focus on supporting the physician and patient's clinical needs. In some cases, patients would be handed off to a centralized care management model, where any chronic conditions can be addressed. Once the SDOH needs were met, the patient could focus on their health concerns and actionable behavior changes. Members of the SNC or CHAP teams would follow up with the patient to ensure they were receiving support and their needs were met. SNCs and care managers share their documentation with physicians, allowing the physician's office to bill for such care management-related activities.
Lastly, PMC collected regular feedback from the practices, practice consultants, and coordinators about common SDOH needs and what resources those patients were using. With that knowledge, PMC leaders and practices reached out to those organizations to formalize meetings about SDOH findings, review of the processes, and ways to collaborate more closely. Examples of these meetings and partnerships include the community ISD, the local agency on aging, the Hurley Food FARMacy, employment support agency ItWorks!, and the local mass transportation authority.
Since 2017, PMC practices collected more than 20 000 SDOH screens on over 17 100 unique patients. Practices would screen for the presence and urgency of the following patient needs:
Data from the screens indicated both pediatric and adult patients had the highest need in the domains of mental health, access to clean water, and transportation. The adults also exhibited a high level of need for financial assistance and education.
After the initial grant program (2017-2019), PMC supported care managers and the SNCs through internal funding, Medicaid partnerships, and funding from the GFHC. Information from the screenings helped the associated practices better understand how their medical office functions as a Patient Centered Medical Home that supports the patients' overall clinical and social needs. The practices have reported better engagement with PMC's care management team when triaging a patient's SDOH needs, recognizing that local community agencies and the mid-Michigan CHAP program can offer the best patient-support programs.
Since beginning to provide wraparound services for patients that provide care management and SNC support, PMC has seen a dramatic shift in key patient measures. During the State Innovation Model (SIM) program that initially funded the efforts, PMC demonstrated a 12% decrease in the cost of care. PMC also showed a 15% reduction in emergency department utilization among the managed Medicaid population—a change that continues—and PMC has some of the lowest emergency department utilization rates of the region and state in all lines of business.
While PMC has made progress in screening patients for their SDOH needs, the group sees some opportunities for improvement. PMC uses a standardized SDOH screening tool, but the independent nature of the network's primary care practices allows for a variety of policies, procedures, and methods for disbursement and data collection. For example, at some PMC practices the screen was built electronically into the EHR for team members to complete the survey while rooming a patient, thus allowing for the practice to quickly gather individual results. At other practices, the patient would complete the form on a paper document, which would later be scanned into the EHR in non-discrete form. Thus, it requires PMC members to be creative in consolidating and analyzing results. Despite such challenges, PMC continues to focus on and promote the importance of SDOH screening and boost awareness of the community's challenges, as well as the many opportunities physicians have of supporting them.
Professional Medical Corporation is a network of more than 460 dedicated independent physicians (approximately 200 practices) in communities around Flint and Genesee County, Michigan. PMC is committed to the advancement of health in the community through high-quality, innovative, and high-value patient care. PMC values transparency, collaboration, trust, and mutual respect for all primary care and specialist members.