Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Consideration

Authors: Caitlin Thomas-Henkel and Meryl Schulman, Center for Health Care Strategies

This resource examines how organizations participating in Transforming Complex Care, a multisite national initiative funded by the Robert Wood Johnson Foundation, are assessing and addressing Social Determinants of Health (SDOH) for populations with complex needs. It reviews key considerations for organizations seeking to use SDOH data to improve patient care.

Included:1) selecting and implementing SDOH assessment tools 2) collecting patient level information related to SDOH; 3)creating workflows to track and address patient needs; 4)identifying community resources and tracking referrals.

Social Determinants of Health for Rural People

The Rural Health Information Hub

This resources discusses the contributing social factors that impact the health of rural residents. It provides a guide that focuses on the barriers and challenges that rural residents experience and discusses the impact of and documenting rural differences related to: Income-level, educational attainment, race/ethnicity, and health literacy.

Health Disparities Road Map

Developed by American Institute of Research (AIR) in partnership with IPRO HQIC

This resource discussed how Person and Family Engagement can help hospitals achieve health Equity in Health Care Quality and Safety.

The American Institutes for Research (AIR)—a partner in the IPRO HQIC program—identified six overarching strategies to guide hospitals in meaningfully engaging patients and families in health care. This document describes how to apply these strategies in ways that can help hospitals achieve equity in care quality and safety and address barriers to uniform engagement.

Person and Family Engagement and Health Equity

Developed by American Institute of Research (AIR) in partnership with IPRO HQIC

Person and family engagement (PFE) is recognized by the Centers
for Medicare & Medicaid Services (CMS) as a promising way to
address health and health care disparities and achieve equity in
quality and safety
. Applying PFE equitably means including
patients and families from all backgrounds as equal and active
partners in their health care. Doing so can help ensure that all
patients reap the benefits of engagement in their healthcare.

Hospital Roadmap for Person and Family Engagement (PFE): Achieving the Five PFE Best Practices to Improve Patient Safety and Health Equity

American Institutes for Research (AIR)/IPRO HQIC

This PFE Roadmap provides practical guidance to help hospitals implement five PFE best practices:

  1. Implementation of a planning checklist for patients who have a planned admission
  2. Implementation of a discharge planning checklist
  3. Conducting shift change huddles and bedside reporting with patients and families
  4. Designation of a PFE leader in the hospital
  5. Active Person and Family Engagement Committee or other committees where patients are represented and report to the board

Minority Health SVI

US Department of Health and Human Services offices of Minority Health

The Centers for Disease Control and Prevention (CDC) and U.S. Department of Health and Human Services (HHS) Office of Minority Health developed the Minority Health Social Vulnerability Index (SVI) to enhance existing resources to support the identification of racial and ethnic minority communities at greatest risk for disproportionate impact and adverse outcomes due to the COVID-19 pandemic. Given evidence on common factors contributing to social vulnerability, the MH SVI could potentially be applied to other public health emergencies.

Hospital Roadmap for Person and Family Engagement (PFE):Achieving the Five PFE Best Practices to Improve Patient Safety and Health Equity

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

A growing body of work—captured in peer-reviewed
literature and the experiences of hospitals and health
systems across the United States—highlights the benefits
of PFE, suggesting that successful implementation of PFE
practices can contribute to better outcomes. This PFE Roadmap provides practical guidance to help hospitals implement five PFE best
practices.

All-Cause Harm Resource

This resource explains what All-Cause Harm is, why it is important and then dives into each of the processes it takes to prevent All-Cause Harm. Eight priority focus areas for the Hospital Quality Improvement Contract (HQIC) are illuminated and strategies to monitor compliance are provided.

All-Cause Harm Resource, Recording and Slides from the IPRO HQIC All-Cause Harm “launch” on March 29th, 2021.

Person and Family Engagement
and Health Equity – Summary

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

This is a summary table that describes the six strategies for engaging with patients and families in equitable and meaningful ways. Although the order of the strategies in the table is based on hospitals’ experiences, hospitals do not need to implement all six strategies at once, or in this order.

PfP Strategic Vision Roadmap for
Person and Family Engagement (PFE)

This material was prepared by American Institutes for Research (AIR). It is redistributed by IPRO HQIC, a Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS).

The purpose of the revised Roadmap is to provide practical guidance to help the Hospital Improvement Innovation Networks (HIINs), hospitals, and other PfP partners achieve a shared vision of PFE and meet the five PFE metrics.

The Roadmap contains information about:
• definition and core principles of PFE;
• role of PFE in patient safety;
• the intersection of PFE and health equity;
• definition, intent, and benefits of each PFE metric, as well as tips and resources to help
meet each metric and hospital success stories; and
• six PFE strategies to meet the five PFE metrics.

Pressure Injury- Learning and Action Network (LAN) May 24th 2021

IPRO & Telligen Hospital Quality Improvement Contractors (HQICs)

The LAN included:

  • A presentation of aggregated results from the IPRO & Telligen HQIC Hospital Baseline Assessment specific to pressure injury
  • An interactive discussion with quality and performance improvement subject matter experts on pressure injury identification, prevention, and management.

Attendees had the opportunity to discuss:

  • Pressure injury challenges in small rural and critical access hospitals (in general and with COVID-19)
  • Approaches to overcome these challenges, including patient and family engagement and health equity strategies.

Hospitals left “in action” with a variety of strategies and 17 salient resources for the front-line to further efforts in All-Cause Harm (Pressure Injury) prevention and management.

Safer Together: A National Action Plan to Advance Patient Safety

Institute for Healthcare Improvement (IHI)

Safer Together: A National Action Plan to Advance Patient Safety provides clear direction that health care leaders, delivery organizations, and associations can use to make significant advances toward safer care and reduced harm across the continuum of care. This resource also includes a Self-Assessment Tool & Implementation Resource Guide. Resource also includes case examples on engaging patients and families in safety.

Eliminating Disparities to Advance Health Equity and Improve Quality

MHA Keystone Center

The MHA Keystone Center encourages organizations to use this guide to assess the current level of hospital implementation around key strategies aimed at reducing disparities to achieve equity and improving quality. This resource will guide organizations to prioritize and act on identified gaps so that deliberate and purposeful action is taken to ensure that the outcomes across all patient populations are equitable. Sections of the guide include:

Section 1: Understanding Key Terms

Section 2: Why Equity in Care Matters

Section 3: Strategic Pillars on the Journey Toward Equity

Section 4: Recommendations for Action

Section 5: Levels of Implementation

Section 6: The MHA Keystone Center’s Dedication to

Achieving Health Equity

Section 7: Resource Compendium

Training and the Culture of Learning: Health Equity Resource Series

American Hospital Association (AHA) Institute for Diversity and Health Equity (IFDHE)

To support hospitals and health systems starting from different points on their journey to achieve health equity, the AHA’s Institute for Diversity and Health Equity (IFDHE) is releasing a series of toolkits to share evidence-based practices to inform organizational next steps for the following topics:

  • Data collection, validation, stratification and application of patient information to address disparate outcomes
  • Cultural humility and implicit bias training and education
  • Diversity and inclusion in leadership and governance roles
  • Sustainable community partnerships focused on improving equity

Each toolkit is designed to be informative, whether organizations have already deployed health equity tactics and strategies or if they are at the early stages of implementation. Each helps lay the groundwork for an in-development equity roadmap to support hospitals’ and health systems’ efforts toward achieving high-quality, equitable care for all. This toolkit focuses on training and education strategies and approaches to encourage cultural humility and overcome implicit bias.