SDOH Screening for Patient-Centered Approaches & Care Team Optimization
Welcome!
This page was created to give you fluid access to all materials provided during the training. You will find all resources discussed or presented, as well as a recording and copy of the slides available for download.
Training Description
In this three-part webinar series hosted by the National Nurse-Led Care Consortium (NNCC) and Louisiana Primary Care Association, Inc., participants can expect to learn about the importance of social determinants of health (SDOH) and whole-person wellness to improve chronic disease management and outcomes. Presenters will showcase promising practices for patient-centered approaches to care by assessing patients’ SDOH needs and care-team roles and role optimization. Further discussion will include reviews of SDOH screening tools, implementing team-based processes for SDOH coding and documentation, and referrals to community-based organizations. Upon completing the training, participants will know how to optimize staff for improved team-based chronic disease management, select an SDOH tool and implement a screening, documenting, and referral protocol for population health management. In addition, there will be an overview of Findhelp, the leading social care referral network, and a health center that will showcase its success with team-based care and SDOH screening implementation.
Learning Outcomes
Explain the importance of SDOH screening, data capture, and closing the loop on referrals for patients with chronic disease management needs.
Identify tools and resources, including FindHelp, to ensure consistency, accuracy, and complete data capture when operationalizing SDOH screening workflows.
Pilot a small test of change to implement an SDOH screening and referral process for a portion of their patient population.
Syllabus
Session 1: SDOH Screening & Coding
In part one of this webinar series, learners will be introduced to the importance of SDOH data to inform practice, SDOH screening tools, the process for selecting which tool will be used, and how it will be administered. In addition, presenters will highlight the value of documenting and coding SDOH screening results into the EHR and promising practices for team-based strategies for collecting SDOH data and translating data into actionable steps for chronic disease management.
Learning Objectives
Understand the importance of SDOH screening, data capture, and reporting for population health management
Summarize SDOH assessment tools and their implementation to identify challenges and barriers to use in primary care.
Examine data collection models to understand how to translate patient-generated information into actionable data.
Slides
Module1_SDOH Screening and Coding_LPCANNCC SDOH Webinar Series.pdfRecording
Resources
Screening
Manchanda R , Gottlieb L . Upstream risks screening tool and guide
Integrating Social And Medical Data To Improve Population Health: Opportunities And Barriers
CMS The Accountable Health Communities Health-Related Social Needs Screening Tool
Victorian Healthcare Association Population Health Planning Framework
Principles for Patient-Centered Approaches to Social Determinants of Health Screening
Coding
Using Z-Codes: The Social Determinants of Health Data Journey to Better Outcomes
Quick Reference for Pediatric Z-Codes by the American Academy of Pediatrics
Session 2: Care Team Optimization
In part two of this webinar series, learners will be introduced to the principles and values of effective team-based care. The foundations of care teams and tools and resources will be presented to support the ongoing evaluation of existing care teams. Care team communication and workflows will be discussed, and participants can learn promising practices of organizational integration of case management, community health workers, pharmacists, and social workers for supporting those with unaddressed social risk factors.
Learning Objectives
Explore promising practices for mapping an SDOH screening workflow and operationalizing other screening processes.
Describe roles and responsibilities for SDOH screening to organize care team optimization.
Identify tools and resources to ensure consistency, accuracy, and complete data capture when operationalizing SDOH screening workflows.
Slides
Module2_Care Team Optimization LPCANNCC SDOH Webinar Series.pdfRecording
Resources
PDSA
Foundations of the Care Team
Core Principles & Values of Effective Team-Based Health Care
Understanding and improving teamwork in organizations: A scientifically based practical guide
Care Team Role Optimization
Optimize the Care Team by Institute for Healthcare Improvement
Community Health Worker/Peer Workforce: Recruiting and Hiring for SDOH Screening
SDOH Screening Workflows
View slides 26 - 34 in the slide deck above
ComuniHealth Presentation Resources
A Randomized Trial of Food Insecurity Screening in the Emergency Department
A Randomized Trial on Screening fo Social Determinants of Health: the iScreen study
Meeting Individual's Social Needs Falls Short of Addressing Social Determinants of Health
Pediatrics
Session 3: Referrals to the Community and Closing the Loop
In part three of this webinar series, participants will learn how to support patients with SDOH needs by referring them to community-based organizations and closing the loop on those referrals. Presenters will demonstrate creating a referral process using the care team and patient input for optimal and reliable execution. In addition, learners will understand the importance of data sharing and governance practices between health centers and community resources.
Learning Objectives
Arrange and pilot workflow and staffing processes to refer patients to SDOH supports
Demonstrate strategies to establish resource networks that align with health equity frameworks for referral management and integration of holistic care
Recognize tools to sustain the implementation and evaluation of referral processes
Slides
FINAL module 3_ referrals and closing loop (1).pdfRecording
Resources
Referral Platforms
Institute for Healthcare Improvement Guides
PRAPARE Implementation and Action Toolkit
LPCA ASSIST
About Us
Established in 1982 as a non-profit organization, the Louisiana Primary Care Association, Inc. (LPCA) promotes accessible, affordable, quality primary healthcare services for the uninsured and medically underserved populations in Louisiana. It is a membership organization of Federally Qualified Health Centers (FQHCs) and supporters committed to the goal of achieving healthcare access for all.
The National Nurse-Led Care Consortium is a nonprofit member-supported organization working to strengthen community health through quality, compassionate, and collaborative nurse-led care.
The NTTAP team at NNCC delivers training and technical assistance to public housing primary care health centers to enhance clinical practice and improve skills and capacity of health centers to meet health care needs of residents of public housing.