Social Determinants of Health Data Users Group Meeting

1. Social Determinants of Health Data Users Group Meeting Jasmine Page, MPH Health Care Data Specialist June 29, 2016 1PM

2. Group Purpose Provide a space for community organizations interested in addressing the social determinants of health to come together to share information and ideas, gain knowledge of community programs currently addressing SDOH, and engage with partners to generate synergy.

3. Agenda • Defining and Understanding the Homeless population • Health Center Case Study on Collecting SDOH • PRAPARE as a tool to collect SDOH • Supportive Housing as a SDOH and models that work • Discussion

4. Presenters • Darlene Jenkins, DrPH • National Health Care or Homeless Council • Marianne Savarese, RN, BSN • HCH program of Manchester, NH • Joan Tulk, RN, MPH, CPHIMS • Community Health Access Network (CHAN) • Lori Phillips-Steele • Corporation for Supportive Housing

5. Connection between Homelessness and Health June 29, 2016 Darlene M Jenkins, DrPH, MPH, CHES Senior Program Director National Health Care for the Homeless Council

6. National Health Care for the Homeless Council • National nonprofit • Established in 1986 • National Cooperative Agreement with Health Resources and Services Administration (HRSA) • Training and Technical Assistance to Health Care for the Homeless health centers, currently 296 HCH primary care sites • Membership Organization • Work accomplished through collaborations, members and committees • Sponsor – HCH PBRN – 61 members

7. Resources • Adapted Clinical Guidelines • Policy Briefs • Fact Sheets • Webinars • Toolkits • Quick Guides • Annual Conference and Regional Trainings www.nhchc.org

8. Two Challenges

9. Defining Homelessness Department of Health and Human Services (HHS) • individual who may live on the streets; stay in a shelter, mission, single room occupancy facilities, abandonedbuilding or vehicle • “doubled up,” a term that refers to a situation where individuals are unable to maintain their housing situation and are forced to stay with a series of friends and/or extended family members. • released from a prison or a hospital may be considered homeless if they do not have a stable housing situationto which they can return. • Source: [Section 330 of the Public Health Service Act (42 U.S.C., 254b)]

10. Defining Homelessness U.S. Department of Housing and Urban Development (HUD) • lacks a fixed, regular, and adequate nighttime residence, which includes a primary nighttime residence (shelter, street) • Individual or family is being evicted within 14 daysfrom their primary nighttime residence • Has moved two or more times in the 60 days immediately prior to applying for assistance • also includes other markers of chronic housing instability • Source: Homeless Emergency Assistance and Rapid Transition to Housing Act of 2009 (P.L. 111-22, Section 1003

11. The Definition of Homelessness The term “homeless individual” means an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and an individual who is a resident in transitional housing. Source: Public Service Health Act, Section 330(h)(5)(A)

12. Identification of Homelessness - Typologies Source: National Health Care for the Homeless Council . (January 2013 ). “Typologies of Homelessness: Moving Beyond a Homogeneous Perspective.” In Focus: A Quarterly Research Review of the National HCH Council . [Author: Sarah Knopf, Research Assistant.] Nashville, TN: Available at: www.nhchc.org

13. Who is homeless? Photo by Sharon Morrison

14. Who is Homeless by the Numbers? • Chronically homeless - 17% ( 96,275 ) Individuals: 83,170 People in families w/ children: 13,105 • Estimated 1 to 1.7 million of youth are homeless in a given year (1/3 of all individuals are youth - age 24) • Large percentage (20% -40%) identify as LGBTQ • Estimated 25-50% of the homeless population has a history of incarceration • In 2014, 1.49 million people stayed in emergency shelters or transitional housing • Estimated elderly homelessness will increase by 33% in 2020 • Homelessness is pervasive in rural areas • Sources: U.S. Department of Housing and Urban Development (November 2015). The 2015 Annual Homeless Assessment Report (AHAR) to Congress: Part 1 Point in Time Estimates of Homelessness. National Health Care for the Homeless Council. (June 2016). Advance Care Planning for Individuals Experiencing Homelessness: A Quarterly Research Review of the National HCH Council, 4:2. [Author: Claudia Davidson, Research Associate]. Nashville, TN: Available at: www.nhchc.org.

15. Why are People Homeless? Homelessness Poverty Substance use disorders Bankruptcy Lack of affordable housing Unemployment/economics Domestic violence Medical/mental health Issues Unsuccessful transition from military Prior history of homelessness Prior history of incarceration Adverse childhood experiences (ACEs)

16. Health and Homelessness Source: Homelessness, health, and human needs. Institute of Medicine National Academies Press, 1988

17. Mortality and Morbidity Source: National Health Care for the Homeless Council. (June 2016). Advance Care Planning for Individuals Experiencing Homelessness: A Quarterly Research Review of the National HCH Council, 4:2. [Author: Claudia Davidson, Research Associate]. Nashville, TN: Available at: www.nhchc.org.

18. Health and Homelessness Photo by James O’Connell Photo by James O’Connell

19. Prevalence of Health Conditions Source: National Health Care for the Homeless Council. (June 2016). Advance Care Planning for Individuals Experiencing Homelessness: A Quarterly Research Review of the National HCH Council, 4:2. [Author: Claudia Davidson, Research Associate]. Nashville, TN: Available at: www.nhchc.org.

20. Health Status of Health Center Users by Housing Status Source: Lebrun-Harris, L. A., Baggett, T., Jenkins, D. et. al.(2012). Health status and health care experiences among homeless patients in federally supported health centers: findings from the 2009 patient survey. Health Services Research

21. Factors Contributing to Health Source: County Health Rankings ,RWJF 2015

22. Social Determinants, Homelessness and Health Housing Social Isolation Transportation Employment Income/ Benefits Immigration Safety Food Security

23. Social Determinants of Health June 29, 2016 Marianne Savarese, RN, BSN Program Coordinator/COO HCH program of Manchester, NH and Board Director for National HCH Council

24. Identifying Homelessness • Multifaceted / Comprehensive Assessments • Over time as trust is engendered • Begins w/ Street Outreach / Engagement • Continues thru Primary Care visits • Extends via Care Coordination in Supportive Housing and Housing First settings • HCH program becomes a Support System / the “Primary Caring” entity for every Homeless patient

25. Why are People Homeless ? • Heterogeneous Group • Reasons of Disconnection / Disenfranchisement • Bio-Psycho-Social / Socioeconomic Factors • Different Contexts / Circumstances / Journeys • Each person who is homeless has a Unique Story to tell • ALL who are Homeless have 3 Traits in Common*: • ( * by Kim Hopper / Ellen Baxter ) • Poor • Isolated • In Crisis

26. Assessments for SDOH at HCH • Searching for that Unique Story … while assessing for: • Poverty: Resources / Means / Spirit / Hope • Isolation: Mental Illness / Estrangement • Crisis: akin to Victims of Disaster / Violence

27. SDOH Assessment Tools at HCH • Intake Registration Form by Front Desk Staff • Social Work – Needs Assessment • Health Questionnaire / Nurse Assessment Tool • Family/Social History by Nurse/BH or Med Provider • In Addition to Medical / BH / Clinical Evaluations for acute and chronic disease or conditions • SDOH performed during outreach tour or clinic session visit by various members of the team

28. Areas of Focus / Inquiry for Disparities and SDOH at HCH Manchester • Housing Status ( street / shelter / transitional / double up) • How long Homeless ( acute or chronic / how many episodes & years ) • Level of Education achieved / Literacy Level • Age / Marital Status • Race / Ethnicity / Language / Interpretation • Veteran Status • Entitlements / Health Insurance Status • Employment / Wages / SSI-Disability • Prison / Jail / Incarceration • Domestic Violence / History of Abuse as Child • Age of 1st Drink or Drug • Family History SUD • History IVDU • Head Injury – points to cognitive impairment / learning disability

29. Assessments / Needs point to Interventions • Housing placements / referrals / coordination • Acute or Chronic status – suggest potential • Transportation / Pharmaceutical Needs • Crisis Intervention / BH needs / DV Safety Needs • Pre-Vocational counseling / coaching / employment • Eligibility / Entitlement Application Assistance • Escort / Referral assistance to Specialty Care • Medication Adherence/Chronic Disease MngmtEduc • Care Coordination w/ Probation & Parole • SBIRT

30. HCH Care is Dictated by SDOH • If we do not address SDOH, we cannot improve Medical and BH outcomes and conditions • If we do not address SDOH, along with Med and BH needs, we cannot end a person’s homelessness. • Homelessness and other SDOH are inextricably linked to Health. HCH care cannot happen without addressing SDOH • PRAPARE effort will assist HCH w/ SDOH data collection within EMR / EHR for future analysis and tracking

31. Tool to Address SDOH

32. Health CentersAddressingtheSocialDeterminantsofHealth Protocolfor Respondingto andAssessingPatientAssets,Risks,andExperiences(PRAPARE) Background Theobjectiveofthisprojectistohelpcommunity health centers and other providers assess and addressthesocialdeterminantsofhealth(SDH)by creating, implementing, and promoting the Protocolfor Responding toand AssessingPatient Assets, Risks,and Experiences (PRAPARE).Bygoing beyond medical acuity to identify patient risks related to the SDH, PRAPARE positions health centersandotherproviderstobetterunderstand and manage their patient populations. PRAPARE willinformthedevelopmentofnewprogramsand partnerships that ultimately improve health outcomesandcurb healthcare spending. PRAPAREdata lays the foundationtoachievegoalsonmany levels.

33. ProjectTimeline Accomplishments to Date • Developed Tool • Tool informed byresearchand stakeholder input • Aligns with national initiatives, including Healthy People 2020, ICD-10, andthe Instituteof Medicine’sRecommendedSocial andBehavioral Domainsand Measures forthe Electronic Health Records • Selected 4ImplementationTeams througha competitiveprocess • Performed cognitive testingof PRAPARE: demonstratedeaseof use andledtointerventions • Built EHR templatesforNextGen, eClinicalWorks,Epic,&GECentricity • Developed WorkingDefinitionofRisk

34. Health CentersPilotingPRAPARE Protocolfor Respondingto andAssessingPatientAssets,Risks,andExperiences(PRAPARE) FourImplementationTeamsconsistingofatleastonehealth centerandonehealthcenternetworkwillparticipateina Learning Community(LC)topilot-testPRAPAREin2015.Overoneyear,theLCwillintegratetheprotocolintohealthcenters’workflow, create Electronic HealthRecord (EHR)templates,anddevelopinterventionstorespondtotheSDHrisks. Teams reach statesacrossthe country, aiding with the nationaldissemination ofPRAPARE. AllImplementationteams haveademonstratedhistory ofcommitment toaddressing patient SDH. AllLChealthcentersites arecertifiedor pendingcertificationaspatient-centeredmedicalhomes.Teamshavepriorexperience collectingandrecordingdataonpatientsocialhistoryanduseofenablingservices,whichhelppatientsovercomenon-clinical barrierstoaccessingcare.Teams have collected dataforenabling servicessuchas eligibility assistance and financial counseling, interpretation,casemanagement,healtheducation,andtransportation.ThisdatahasbeenusedbyLCmemberorganizations to identify and support the development of needed programs, connect patients with community resources and patient navigators, target patientsfor specific screenings, andidentifythe levelofcaremanagement a patient needs.

35. Thisprojectwasmade possible withfunding fromthe Kresge Foundation,the Blue Shieldof CaliforniaFoundation, andthe Kaiser Permanente NationalCommunityBenefitFund atthe East BayCommunityFoundation. For more informationaboutthisproject, please contactMichelleJester atmjester@nachc.org orvisitthe “Resourcesfor Addressing Social Determinants”folderathttp://www.healthcarecommunities.org/ResourceCenter.aspx August2015

36. PRAPARE:Protocol for RespondingtoandAssessingPatient Assets,Risks, and Experiences Paper Versionof PRAPAREfor Implementation AsofApril 15, 2015 Personal Characteristics 7. Whatis yourhousing situationtoday? 1.Are you Hispanic orLatino? 2. Whichrace(s) are you?Checkallthat apply. 8. What addressdo youlive at? Street:City,State,Zipcode: 3. At any pointinthe past 2years, has seasonor migrant farm work been youroryourfamily’smainsourceof income? Money & Resources 9. Whatis the highest level ofschool that you have finished? • Have you been dischargedfromthe armedforcesof the UnitedStates? • 10. Whatis yourcurrentworksituation? • Whatlanguage are youmostcomfortable speaking? 11. Whatis yourmaininsurance? Family &Home 6. How manyfamilymembers,including yourself, do you currentlylivewith? Formore informationabout this tool, please contactMichelleJester atmjester@nachc.orgorvisit the“Resources for AddressingSocialDeterminants”folder athttp://www.healthcarecommunities.org/ResourceCenter.aspx

37. 12. During the past year,whatwas the total combined income foryou andthe familymembersyoulive with? Optional Additional Questions 16. Inthe past year,have youspentmore than2nightsina row inajail, prison, detentioncenter,orjuvenile correctionalfacility? 13. Inthe past year, have youoranyfamilymembersyou livewith beenunabletogetanyof the following whenit wasreally needed? Checkallthat apply. 17. Has lackof transportation keptyoufrommedical appointments orfrom gettingyourmedications? 18. Are youarefugee? Social andEmotional Health 19. Whatcountryare youfrom? 14. How often do yousee or talkto peoplethatthatyou careaboutandfeel close to?(Forexample: talking to friendsonthe phone,visiting friendsorfamily,going to churchorclubmeetings) 20. Do youfeelphysically andemotionallysafe where you currentlylive? 15. Stressiswhensomeone feelstense, nervous, anxious, orcan’tsleep atnight because their mindis troubled. How stressed are you? 21. Inthe past year,have you been afraidof yourpartneror ex-partner? Formore informationabout this tool, please contactMichelleJester atmjester@nachc.orgorvisit the“Resources for AddressingSocialDeterminants”folder athttp://www.healthcarecommunities.org/ResourceCenter.aspx

38. Thank You!