Coordinated By:
Medical Neighborhood Referral Infrastructure Project In-Person Work Session August 5, 2016 Record of Learning Meeting Participants Kenton Beachy, Mental Health America of Franklin County Kandy Burch, The Breathing Association Margaret Centofanti, Central Ohio Area Agency on Aging Matthew Dewit, Central Ohio Primary Care Kelci Dillard, YMCA of Central Ohio Maurice Elder, LifeCare Alliance Shanna Huber, Ripple Life Care Planning Linda Gillespie, Central Ohio Area Agency on Aging Megan Gish, Clintonville-Beechwold CRC John Leite, HCGC
Adam Maloon, CliniSync Michelle Missler, HCGC Mary Mutegi, Physicians CareConnection Shawnetta Padgett, Central Ohio Diabetes Association Victoria Redden, CliniSync David Reierson, United Way of Central Ohio Tiffany Simon, Ripple Life Care Planning Barbara Sullivan, Franklin County Office on Aging Jennifer Tiedt, Central Ohio Area Agency on Aging Colleen Wesley, The Breathing Association
Welcome and Framing Thank you to Shanna Huber and Ripple Life Care Planning for hosting the session and providing us with refreshments. To view the slides used during the session, please click here. CliniSync Updates (Victoria Redden & Adam Maloon, CliniSync) CliniSync representatives shared a briefing on upcoming referral tool updates. CliniSync anticipates the next system update to be implemented in quarter four of 2016. They anticipate the update to include the ability to limit referral history for non-covered entities later this year. This would enable those organizations and services to begin participating in the project. Email notifications, improvements to system speed, and other bug fixes should also be included in the update. CliniSync is also working with their vendor to implement the ability to customize search terms when looking for services. Sharing Lessons Learned What are your key reflections from participating in the Medical Neighborhood Referral Infrastructure Project so far? Cultural change in the works. Having trouble to move to CliniSync with current workflow. Doctor buy-in and increased utilization. Education on uses, benefits to clients, services available. Educate clients on security of system. Important to be able to send referrals instantly at the point of care. This is especially true for organizations that work in the field/at patient’s homes. o CliniSync representatives suggested referral forms could be filled out offline and then sent once you are back on a secured internet connection. o Participants suggested connecting with patients prior to your visit to provide them with consent. Important to continue to bring new agencies into the network. Interested in mobility, encouraging partners to use CliniSync at home visits. Keep on forefront, re-train when necessary and learn together. Mobile access to system, educating workers, educating clients Organizational buy-in by management to drive line staff utilization is critical. Change work habits. Project is really about a culture change in your organization. Can be a difficult process, but one that is worthwhile. Would be very helpful to have email notifications for activity in the system.
Exploring Approaches for Increasing Referral Activity Project participants have shown an interest in increasing the number of referrals being exchanged on the tool. Based on learning from other regions implementing referral networks we have found that one way to generate more referrals is by implementing health-related social needs screening processes. Health Leads has created a toolkit to help organizations and communities create screenings to identify health-related social needs. Using the Health Leads framework, session participants spent time in small groups discussing the possibilities of implementing a screening process in our region.
Social Need
Examples
Food Insecurity
Limited or uncertain access to adequate & nutritious food
Housing Instability
Homelessness, unsafe housing quality, inability to pay mortgage/rent, frequent housing disruptions, eviction,
Utility Needs
Difficulty paying utility bills, shut off notices, discounted phone
Financial Resource Strain
Public cash benefits, charity emergency funds, financial literacy, medication under-use due to cost, benefit denial
Transportation
Difficulty accessing/affording transportation (medical or public)
Exposure to Violence
Intimate partner violence, elder abuse, community violence
Behavioral/Mental Health
Stress Anxiety, depression, psychological assets, trauma
Health Behaviors
Tobacco use, alcohol and substance use, physical activity, diet
Employment
Under-employment, unemployment, job training
What are the opportunities and challenges of standardizing the screening process for health-related social needs in the medical neighborhood? Opportunities o Comprehensive o Consistency o Customized screening may be more appropriate based on the variance of demographic served. o Finding uniformity o Goal is improved outcomes for patients. o Improves overall outcomes o Increases referrals being exchanged o Maslow’s hierarchy of needs o More consistency o Providers good starting point o Providers making inquiries to link with needed social services o Same starting place. Challenges o Affects productivity o Avoid duplication of work o Comprehensive screening may put pressure on the productivity rate. May be difficult to handle volume. o Follow up on referrals rather than just providing info. o Hard to make “one size fits all” approach—different practice areas, focus of work with different populations, scope of practice issues o Limited staff resources o Possibly discouraging the client
o o
There is a significant transportation gap. Built screening tool that serves their populations. Time
If we standardized a screening process in Greater Columbus, what health-related social needs would represent a good place to start? Basic needs: food, housing, finances, employment, and transportation Behavioral health issues Develop core screening questions for each agency to incorporate in its existing screening tool. Food security Groups of questions Health/Health behaviors Housing Mental health/trauma/AoD Presenting problem of the patient—what are the client’s concerns Start with the basic needs. Transportation Use needs that already have services available in the referral network. Work on crisis at hand. Closing Based on feedback from participants we will continue to explore screening processes in the coming weeks. We will host our final in-person work session of the year in November, or December. If you are interested in hosting the session, please contact John Leite (john@hcgc.org).
Thank you for participating!