CSMS-IPA 3rd Quarter 2022 Newsletter

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CSMS-IPA 3rd Quarter 2022 Newsletter


Please Join Us for a Webinar Presented By Optum

Understanding the Medicare Annual Wellness Visit

Thursday, October 27, 2022 from Noon - 1PM

Why Attend:
This session will give a detailed overview of what the Medicare Annual Wellness Visit (AWV) entails, and how it differs from a "routine physical exam". 

Click Here To Register

(We recommend using Google Chrome when registering)

Managing Social Determinants of Health (SDOH)

Why You Should Care About SDOH

Are you convinced that good medical care and patient adherence are the only keys to good outcomes? If so, think again. Socioeconomic factors, known as SDOH, influence health outcomes, and often, not for the better. 

SDOH are the conditions in the environments where people are born, live, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks. Differences in SDOH contribute to the stark and persistent chronic disease disparities in the United States among racial, ethnic, and socioeconomic groups, systematically limiting opportunities for members of some groups to be healthy. Centers for Disease Control (CDC March 29,2022) 
Key Parts of SDOH, and Their Impact On Health Outcomes
See the examples below to better understand how SDOH can impact clinical outcomes:
  • May Garcia - A 32-year-old mother of two reluctantly comes to the office because of her frequent severe migraines. She is oddly reticent about the timing of her migraine episodes. Eventually she reveals that she has migraines when her domestic partner threatens her with violence.
  • The Altman family - Janna, Harry and Cora are all under age 10. All are overweight. An SDOH questionnaire reveals that the family suffers from food insecurity and purchases many high calorie foods from a local store where no fresh fruits or vegetables are available.
  • Jaretta Washington - This 82-year-old woman with COPD, often has exacerbations of her illness. She has trouble managing her inhaler. She cannot get a spacer for her inhaler because it is not covered by Medicare and she can’t afford it.
In each of these cases, SDOH, more than medical care, will determine clinical outcomes for each patient. Medical offices that address social determinants will provide far more comprehensive treatment for patients and will achieve a better patient experience.  SDOH have a particularly big impact on preventive testing as rigid low wage job schedules, lack of transportation and being distracted by basic survival needs may be big barriers to getting mammograms, colonoscopies, etc.
SDOH Screening Tools

To effectively help patients in managing SDOH, medical practices should choose an SDOH screening tool. A short tool that is optimized for poor readers is best.  The practice must also create a workflow that starts with patients completing the screening and ends with a referral to community resources and follow-up on referral results. SDOH screening and follow-up should become a routine part of the annual visit or a part of shorter visits if there are signs that a social determinant problem exists.   
There are a variety of SDOH screening tools. Many electronic medical records have them embedded. You can also use the tool in the CIGNA toolkit which was sent to all CSMS-IPA medical practices, or you can log into the CSMS-IPA website to access it.  Other tools are listed in the “Resources” section at the end of this newsletter.
Health Literacy as a SDOH

Health literacy is a key social determinant that is the root cause of many adherence problems. Patients who are not health literate may not understand their illness, treatment plan or medications. To assess health literacy, use the following evidence-based question.

How confident are you in filling out medical forms by yourself?
  • Extremely 
  • Quite a bit
  • Somewhat
  • A little bit
  • Not at all
Any answer of somewhat or below indicates a possible issue with health literacy and subsequent issues with adherence to medical treatment plans.
Workflows for Addressing SDOH in Primary Care
How They Did it - A CSMS-IPA Practice Tackles SDOH
In a recent interview Lorie Owens, Practice Manager of Barochia Internal Medicine, described how the practice adopted a screening workflow for SDOH. Lorie describes this as: “Something new - with insurance companies adopting the idea that things beyond just medical care can keep you healthy.”

The staff started by creating a one-page guide to local community resources. Lorie feels that 211 is the most useful of the resources. They then developed a one-page SDOH screening form that was given out at appointments. Staff were quickly overwhelmed by managing the forms and eventually decided to use them only for annual visits. 
Staff also created a single page community resource form to hand out. They found that patient embarrassment was a big barrier to resolving SDOH issues. Since this is a small practice, staff typically know patients and they use their personal relationships and communication skills to gently support patients in getting help. The staff always emphasize the confidentiality of the process. They are also careful not to push too hard as this can produce resistance.

The practice is taking a new direction on SDOH as their EMR incorporates the PRAPARE form.  They hope to have patients complete the form on tablets and submit them electronically. This will save both time and money for the practice. Lorie feels that this process has been a good thing as it has uncovered some SDOH problems and provided patients with resources that they were not aware of prior to their visit.

Tips for Effective Management of SDOH
  • Utilize local resources - Research or use staff knowledge of local food pantries, diaper banks, medical equipment loan closets, free transportation, domestic violence services and other resources. In the office, post a list with phone numbers. Town websites and senior centers are good sources of information.
  • Test resources yourself - Investigate how easy they are to use, what they offer and how responsive they are to callers or online inquiries.
  • Tread lightly in communicating about SDOH issues. Many patients are embarrassed by their lack of financial resources and other needs. Use active listening skills including open ended questions, reflecting back what you have heard and summarize.
  • Emphasize that the whole process of SDOH referral and follow-up is confidential.
  • Help the patient prioritize and set goals for resolving SDOH issues. Patients will not act if they do not see the SDOH issue as a priority or if they feel overwhelmed with day-to-day survival needs.
  • Where possible, use a warm handoff to community resources. If the patient needs extra help, make a referral to the community resource while he/she is in the office.
  • Follow up on the results of referrals. Call patients to see whether they have followed through on getting help. If not, problem solve with them and make another plan.
  • Check on the status of SDOH issues at the next office visit.
Resources for Managing SDOH

SDOH Screening Tools
The screening tools listed below can be adopted by any practice to uncover patient social determinants of health issues.
SDOH Screening and Management Tools and Techniques
These articles provide practical information on screening for and managing SDOH.
Community Resources for Patients with SDOH Issues
These websites provide both state and national resources and benefits programs for patients.
  • 211 Connecticut – A statewide call center with a huge variety of state resources
A national resource database that can be searched by zip code.
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The Connecticut State Medical Society - IPA (CSMS-IPA) is the largest and only statewide IPA in Connecticut and one of the largest in the nation. The CSMS-IPA is comprised of approximately 7,000 physician members. The CSMS-IPA is governed by a 27-member physician Board of Directors.



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