- William B. Gunn Jr., PhD, Director of Clinical Integration, Connections for Health
- Katherine Cox, MSW, Project Director/Practice Facilitator, NH Citizens Health Initiative, Institute for Health Policy and Practice, University of New Hampshire
- Sandi Denoncour, BA, ASN, RN, Director of Care Coordination, Connections for Health
- Jason Howe, DO, Family Practice Provider, Core Physicians
- Angel Bilodeau, MSW, Social Work Care Coordinator, Core Physicians
Social determinants have a major impact on health outcomes, especially for the most vulnerable populations. Factors such as housing, food, transportation, and other social needs must be considered when providing treatment and care. In its work to improve the health of NH residents and create effective and cost-effective systems of care, the NH Citizens Health Initiative partnered with Connections for Health to provide a year-long practice facilitation opportunity for 8 practices in Seacoast NH. The goal was to expand upon the practice’s knowledge and use of quality improvement science to initiate, improve, or maintain their integration efforts. Practices used the Maine Health Access Foundation’s Site Self-Assessment (SSA) tool to evaluate their level of integration and a facilitated strategy meeting occurred at the practice to develop next steps and opportunities for improvement. Connections for Health used those results to request practice-level proposals to offer 12 months of practice facilitation to help move their goals for integration forward. This presentation will highlight the process of one primary care practice. An interdisciplinary care team comprised of a Primary Care Provider, Medical Assistant, and Integrated Social Work Care Coordinator at a primary care office in Seacoast New Hampshire have been working on addressing the social determinants of health of their patient population. The physician champion will share their confidence in addressing patient complexities and the impact these conversations have on the disease burden of their panel. In addition, this team has collected and utilized data to inform decision making and demonstrate the value of an MSW-level, non-billable clinician. It was apparent to the team that without the crucial role of an engaged and motivated Medical Assistant, implementing a change project would prove difficult. This presentation will highlight the importance of fostering a cohesive team-based approach that emphasizes the critical role each professional has on achieving whole-person care. The team has focused on the “how”to implement a SDOH screening process, build an organizational culture that normalizes SDOH as a standard part of care, and connect with organizations within the community to support patients. This presentation will demonstrate the importance of navigating across three scales to create change for their patients: 1). Micro – Screening patients for SDOH; Warm hand-off to Integrated Social Worker to address patient needs, 2). Meso – Building a culture of whole-person care in the organization; Coordination between Social Work and Nurse Care Coordination; Data collection to support QI efforts, and 3). Macro – Connecting with community based organizations via Community Care Team. The presentation aims to share how taking a measured approach to assessment, planning, implementing, and monitoring over time has been beneficial for a primary care practice at all levels.
- Discuss the importance of harnessing interprofessional team-based care and the community partnerships that advance integration and address the social determinant of health needs of patients.
- Consider engagement in quality improvement processes to address social determinants of health in a primary care setting.
- Understand how practice and patient data can be collected and utilized to inform next steps on implementing change projects.