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Health leads

Health leads. Our vision. Health Leads envisions a healthcare system that addresses all patients’ basic resource needs as a standard part of quality care . The process. Patient-centric, Closed loop. Simple screening tool. Paper-based today. EMR Screenshot.

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Health leads

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  1. Health leads

  2. Our vision Health Leads envisions a healthcare system that addresses all patients’ basic resource needs as a standard part of quality care

  3. The process Patient-centric, Closed loop

  4. Simple screening tool Paper-based today

  5. EMR Screenshot Johns Hopkins children's hospital- epic

  6. Simple categorization of needs

  7. Community resources match need categories Resources meeting client criteria + history of success

  8. resource referral tracking Specific resources for each need identified

  9. Management reports Overview of activity by desk or clinic

  10. Sample Report: Client Needs Categorization of needs opened

  11. Sample Report: Need resolution How did we do?

  12. Health Leads 2013 Program highlights • Helped 11,000+ clients, representing nearly 43,000 household members • 20+ clinics across 6 cities • Top 5 categories of needs • Child-Related (16%) • Housing (14%) • Employment (13%) • Food (12%) • Utilities (12%) • Met at least one need for 60% of our clients • Almost 1000 college student Advocates from 14 universities

  13. Key lessons • Executive Champions are Essential • Workflow Matters • Timing Matters

  14. Executive Champions Engage leaders who • Have already identified SDOH as a critical part of quality care • Are willing to commit financial resources toward identifying, tracking and solving patient’s basic resource needs • Have the authority to prioritize the resources needed to be successful • Physician, Clinic Staff, IT and Legal

  15. Workflow matters • The screening and referral process must be sustainable • Measure it. How many patients screened positive? How many of those screens are documented in the EMR? • The target starting population must be easily identifiable • Ex/ Screening patients between the ages of 5-10 with asthma and who are at risk for obesity is complicated to identify • Start small- learn from a sub-set of the patient panel • Universal screening sounds great, until you are overwhelmed by patient needs surfaced • Pay attention to the details • Where are screening forms kept? Who prints patient labels?

  16. Timing matters • Take advantage of EMR implementations or upgrades • This is a time where process change is already happening, and budget is often available for minor changes • Be aware of budget cycles • Arm clinic leadership advocating for this work with data at budget time • Do not wait for EMR changes to start building a process to identify needs • Building credibility in screening for needs and addressing them will help clinic champions advocate for changes at budget time

  17. Thank you Health Leads envisions a healthcare system that addresses all patients’ basic resource needs as a standard part of quality care

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