Knowing where to start when launching an initiative to gather and analyze data about social determinants of health can be daunting for health systems. Jennifer Polello, senior director of quality and population health at Community Health Plan of Washington, recently described how her organization got started.
Community Health Plan of Washington (CHPW) is a nonprofit health plan that serves the entire state of Washington. It has just over 300,000 members and the majority are Medicaid members. It has a smaller Medicare Advantage line of business that includes special needs populations. “We are dedicated to serving underserved and marginalized populations,” said Polello, who was speaking during a webinar hosted by Arcadia, a data analytics vendor. “Our mission is to be a leader in whole person, equitable care. We live and work in the communities in which we provide care, so we're very invested in this process and the work that we're doing around social determinants.”
The health plan was founded in 1992 by 20 federally qualified health centers (FQHCs) that are located across the state of Washington. CHPW is the governing body of the plan, and it also provides advocacy and other services for the community health centers.
“All of our 21 federally qualified health centers across the state are working together to tackle this problem of social determinants and how to collect data in a comprehensive way,” Polelo said. “What do we do with it? How do we influence providers? How do we help care teams utilize the data that we are collecting? Like many organizations, we've struggled with this and had kind of a rough, rocky journey along the way.”
The organization began in 2016 and 2017 to look at the availability of social data across the network. They had some providers tracking this work with paper forms and not putting Z codes on claims. (Z codes are used by clinicians to note stressful situations that might have a negative impact on mental health.)
Polello said it can be daunting when you're an organization just trying to figure out where to start on an initiative like this. “You may or may not have comprehensive data to lean on to show you where you should start. We were fortunate enough to look across our population to figure out where were those areas of greatest needs, and where we should focus our resources,” she said. “Employment, housing, food insecurity and transportation were among our top social needs, and where we decided to build out resources and really dig into areas where we could have a greater impact. We began working with our community partners to understand what challenges lie within each community. Everybody's experiencing long wait times for housing resources, for example.”
Like many plans, CHPW has found resources to help connect members to transportation resources. “We looked at our data and found that members experiencing transportation issue were 1.7 times more likely to have an ER visit in the coming year as opposed to those who did not have transportation issues,” Polello said, “so we really started paying attention to how we could connect our members. This is an important piece of medical care even if it's not direct medical care.”
CHPW also is trying to find creative ways to connect with members who are the hardest to reach. “We've got a pilot project this year where we've got an advocate going into members’ homes that are identified as high risk on the medical side or social side or a combination of both,” she explained. “These medical advocates are visiting the members in the home, but more often than not, they're transporting them to a medical appointment and taking them to the pharmacy to make sure that they're getting their medications and helping them figure out their medications and their next appointments in between visits. We are really excited to see how this medical advocate program goes in terms of not only impacting transportation of the members but helping with social isolation.”
Polello stressed that housing is a major problem in Washington, calling it “the elephant in the room.”
“I don't think our state is unique in terms of having way more referrals for housing than there are resources. I think that's a common problem in most communities,” she said. “We know that the unhoused have higher medical costs and poor outcomes. We've partnered with a couple of our communities to look at medical respite programs to help those members who are discharging from and inpatient stay to have some place to rest and recover from their illness, but, we have long wait times for medical respite as well as for general housing resources. A lot of this goes back to policy and providing resources for those community-based organizations that we work with. We're working with a platform that connects our social service workers, our care managers, to social services in different communities that we serve. It's difficult, especially when talking about housing, because a lot of these community-based organizations have closed the door, so to speak, to accepting these referrals. From a policy standpoint, how can we work with these community-based organizations? When they partner with plans like us or larger health system organizations, there's more of a chance that they get community grants.”
Improving SDOH data collection
Polello was asked about challenges with collecting SDOH data to act upon. “We've had quite the journey collecting data across our network,” she said. “Five or six years ago when we started this process, we had about a third of our centers regularly capturing SDOH data. About 70 percent of them were regularly adding the necessary Z code on the claim.”
They surveyed the providers to get a sense of what they're looking at in terms of social determinants and how they're collecting that information and how they're using it across their organization. “We found that a majority of them were using paper surveys, like a prepared template to capture that, which is unfortunate because oftentimes that wasn't making it back into the EHR,” she said. “We had some clinics that were capturing it on a couple of providers, but not across the entire clinic. After that effort, we provided some resources to our FQHCs to help them improve their data collection and capture the work process and were able to implement electronic capture of that data, which really helped us improve our ability to see that data. But we also did a lot of training with billing teams and coders to help them be more aware of Z codes and why it's important. It's not always the provider that has to put a Z code on a claim, for example, and a lot of our FQHCs didn't know that a social worker could add that Z code.”
The plan also looked at charts and claims it had had received and gave the clinics a list of members that it thought were homeless based on the information it had, and asked them to see if they could verify that. “That has improved our coding on housing alone,” she said. “We're branching that out to transportation and social isolation as well. But just getting that general awareness and having time and space to train those care teams is really important.”
Polello also described some of the ways her organization uses Arcadia’s platform and registries. “You can look at census data to apply to your patient population with chronic conditions, race, ethnicity, language,” she said. “You can slice and dice your registries in a number of ways and create custom reports, which have been really helpful to our different care teams looking to serve different populations. One of our providers has got a diabetes initiative going on right now. They are using the registry and adding exams for diabetes — the eye exam, the kidney exam, to the registry, plus adding race, ethnicity, language, and some of those social factors that they could work with the community partners to not only identify those members, but help with additional outreach strategies,” Polello explained. “Text messaging that we've used with the platform has been extremely helpful and enabled us to connect with those populations that we're looking to define when we're creating these segmented reports. The Arcadia data has really helped us elevate our social data capture and then just make it that much more actionable across the network.”
Another major challenge in doing this work involves the staffing challenges that the healthcare industry has had over the last few years with the pandemic. “It's been difficult for us with those staffing shortages to find time for meaningful training, not only around SDOH data capture in terms of billing and coding, but having space and time for that community collaboration that is so needed in this effort,” Polello said. “We've been able to work with our providers and care teams for bite-sized trainings that they can access on their phones. We're talking like eight to 10 minutes at most. We found that has been really helpful to just elevate the providers’ awareness when they're visiting with the member and also helping the care teams that are doing the pre-visit planning efforts and making sure that the effort at the visit is maximized.”