At Phoenix Children’s, an Intense Focus on SDOH
Every year, more patient care organizations are participating in newer models of care and developing innovative approaches to addressing population health and the social determinants of health (SDOH).
One organization that has leaped into such work is Phoenix Children’s, in Phoenix, Arizona. As the organization’s 2023 Annual Report notes, “Addressing the effects of social determinants of health (SDoH) has become a major focus for Phoenix Children’s. SDoH can have a direct and negative impact on a child’s physical and mental health—and we’re committed to improving the health and wellbeing of every family we serve.”
Indeed, that annual report states, “Phoenix Children’s created an SDoH program to screen for and address patients’ socioeconomic needs. We started by developing a standardized survey to assess SoH across 14 domains. Since we launched the survey in October 2022, more than 262,000 families have participated—with staggering results. Nearly 20 percent report at least one SDoH issue, including childcare access, food insecurity and unmet mental health needs. Today, our Care Navigators connect families in need with resources offered within Phoenix Children’s, like group therapy to help with concerns about bullying, access to a mobile food pantry, and support with transportation services for medical care. Recognizing some needs extend beyond our reach, we’re also partnering with community organizations and initiatives to close gaps in needs for vulnerable families. We continue to prioritize our SDoH efforts, as healthy kids grow up to be healthy adults who strengthen and lead their communities. It’s our goal to provide the best outcome for each child—and every future adult—in our care.”
And, while many organizations rely on paper SDoH screenings, the leaders at Phoenix Children’s leveraged their own proprietary technology that had been successful in other parts of the health system and customized it to build a dashboard and an automated, text message screening process. Since all the SDoH data is fed into an easy-to-read dashboard, one care coordinator can immediately analyze the information and the needs and connect patients with community resources. Among the SDOH issues tracked inside the organization’s dashboard are “food,” “utilities,” “childcare,” “making ends meet,” “mental health,” “clothing,” “transportation,” “utilities,” and “employment.”
Vinay Vaidya, M.D., senior vice president and chief medical information officer at Phoenix Children’s, spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland regarding his evolving role in the organization and his leadership of the health system’s SDOH initiative. Below are excerpts from that interview.
Let’s begin by conversing about your role at Phoenix Children’s. You’ve been there quite a long time, and I know that your role has evolved over that time.
That’s right; my focus has changed over 17 years. Like every other CMIO, the first several years were about laying the foundations. Then came the phase of optimization; many hospitals get stuck in that phase. I quickly got out of that. Why did we implement EMRs? For the benefit of patients and physicians. So I’ve been focusing on clinical excellence through data analytics, while my associate CMIO is focusing on the day-to-day operations. Put simply, my focus has changed over time to that of helping to lead clinical excellence across the enterprise. It’s a very gratifying role.
And this current work on the social determinants of health is a significant part of that evolution, correct?
Yes, we launched the program two years ago, and it’s been amazing the extent to which the program has taken off. And it is a shocking statement to digest the fact that less than 20 percent of outcomes in healthcare are determined by a healthcare interaction. And we’re shocked in medicine that if I do a great diagnosis and great care delivery and great follow-up, and we have an app, but that will still only impact 20 percent of the patient’s health. And among the elements in that mix are environment, education, food, shelter/housing, etc. And all the factors conspired at Phoenix Children’s to launch this program like a Space X rocket. So, social determinants of health is not a new subject; but what we did was to get together a small group of leaders, as we all understood the need to screen for social determinants, as leaders are realizing everywhere. And with our strong IT background, it was a no-brainer to understand that that screening cannot be accomplished using a paper form. And most hospitals manage it on an inpatient basis, because you can handle it better as a load. It’s much harder to accomplish on an outpatient basis.
But we realized we could not ignore the ED, surgical patients, ambulatory care—anyone who touched Phoenix Children’s. And we didn’t think it would be easy, but we came up with a questionnaire. So we have that infrastructure of rapidly being able to text the patient. And we do a lot of homegrown development. Somehow, here, the “build” has worked for us; it might not work for everybody. But the speed, the flexibility, the nuances we can get.
We were able to slip this into texting processes with patients; that went live in October 2022. So every patient with an ambulatory visit, gets a survey a few days before; and inpatients get it upon admission. And because the data is electronic, we can work with it. The survey results automatically go into the EMR, and the physicians can access it. More importantly, because the data is granular and goes to a data warehouse, we can analyze it.
And we found out that one out of six patients have one or more of 14 SDOH issues: childcare, mental health, food, making ends meet, transportation, housing, employment, healthcare, utilities, medication, phone, utilities, bullying. So, two years ago, 295,280 patients returned the form, and 61,440 answered positive. And we know where the patients are coming from. In fact, among the patients seen just literally today, one patient has reported issues in 12 areas, another in 11, another in 10, and another in 7. And through analysis, we were discovering patterns in the different SDOH elements. It was like drinking from a firehose.
So it felt overwhelming when you first got the data, correct?
Yes, it really did. We put it in a couple of baskets. And these are specialist clinics, right? Orthopedics, etc. And we talk to social workers, we have a patient advisory committee, and we got input from the state, etc. One of the discoveries was that we realized that the general pediatric clinics, which are the ones that screen the patients, wanted ownership of the SDOH, so we shared the data with them. That was appropriate, because the specialists, such as orthopedists, because of the brief amount of time they’ll spend with patients, will feel overwhelmed by the data.
So we gave the information with the general pediatrician. And then we started recruiting staff for this. We operate in a very lean way, with three care coordinators who access the SDOH dashboard. And working with the dashboard, their work is manageable.
Next, we entered into a partnership with the state, and that was a big thing. To be truthful, you and I alone cannot solve the social determinant problems. It’s bigger than any single healthcare organization, and that is a sobering experience. But the state has partnered with us. They’ve partnered with a vendor that manages their HIE. And we’re working with Contexture, the HIE [health information exchange] organization; and they’re partnering with 211, the community service organization. The focus here has been on closed-loop referral, meaning that not only is a referral made by a physician or care team, but that referral is followed up on by ourself. And in order to make an impact, we began with patients who had referenced eight or more SDOH issues. But today, our threshold for closed-loop referrals is five SDOH issues, and soon, we’ll be able to address the needs of patients with three issues.
In other words, you had to begin in a manageable way, and then advance from there, correct?
Yes, that’s right. It’s a cliché to say so, but it’s like boiling the ocean. And Michelangelo was asked how he created “David,” and he said, “I took the hunk of stone from the mountain, and started chipping away the unneeded parts.”
And that’s how we’ve approached this, focusing on first wins. Childcare was something that really emerged as a strong need; and when we approached the state with this, they said, gosh, we need to addressing this issue geographically. And per bullying, we were able to form a mental health group for children, where children were able to talk together, supervised by a mental health professional. And working in that small way, maybe that can start something. And ultimately, this has to be policy, advocacy, legislation.
How have you changed the clinician culture around this?
That’s a great question. It involves all the elements. How have we gotten the physicians to look at this area that wasn’t part of their training, in a short 15-minute visit? In the past several years as I’ve focused on clinical excellence, the physicians started out being curious about the dashboards. And then they realized, oh gosh, I haven’t seen my cystic fibrosis patient for 180 days. So this was a receptive group of physicians who had learned the power of data analytics. So then, you can look at your 5,000 epilepsy patients—who has their condition controlled or not; so our physicians were becoming accustomed over time, primed to look at this kind of data. And every hospital system is like a bell-shaped curve, right? And some physicians who would say, we don’t know what to do about this in a 15-minute visit, but I will look at the chart to figure out what to do next. And looking at sickle cell—if I have a patient whose family is struggling with electricity—your painting a holistic picture is helping me a lot, even if I can’t address everything. So we show physicians what they can handle based on their appetite.
How should CMIOs, CIOs, CMOs, and other senior leaders, think about this?
I think that what is universal is that no one is going to hug their EMR. Implementing solid systems is important; optimizing them is even more important. But you have to understand the law of diminishing returns: at some point, you have to stop “Botox-ing” the EMR. When you free data that is real-time, accurate, and actionable, it changes engagement. You’ve discovered the universal currency about how to engage clinicians. This is not about fancy colored graphs in programs. Culture changes when you give physicians data and treat them like partners. So, don’t get carried away by the next shiny object; use the tool effectively. And physicians are smart people: you provide them with good tools, and then you’ll use them effectively. And these are pretty darned powerful tools. In every problem, if you get the technology, people, and processes right, you’re 90 percent of the way. And working with SDOH means screening every single patient.
