A 2 year demonstration project in Providence
Oregon Family Medicine Residency Clinics to connect
vulnerable families directly to community support
services: the Patient Centered Medical
Home/Community Connection
Health Care Transformation
Flexible Services
AKA - Air Conditioner Bill
What are flexible services?
Flexible services are health related non-State plan services
intended to improve care delivery and member health. They are
cost effective alternatives to traditional services.
Must Support the Following:
Examples:
Achieving Treatment Goal
Small Refrigerator
Shoes
Temporary housing/utility assistance
Food Assistance
Certain CM/Pt. Navigation supports
Scales or BP Monitor for home
Support Groups/Wellness activities
Preventing Decompensation
Diverting From Higher Level of Care
Assisting in Environmental Stability
Managing a Chronic Condition
Health Care Transformation
New Workforce
Oregon’s health system transformation and the federal
Affordable Care Act have emphasized the essential role of
nontraditional health workers in promoting health and delivering
care. Under new legislation, Medicaid dollars can be used
towards funding these positions
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Community Health Worker
Peer Wellness Specialists
Personal Health Navigator
Doula
Peer Support Specialists (MH
and Addictions)
In Development
1. Must work under the
supervision of licensed HC
providers
2. State approved curriculum
& certification process
3. Registry will be in place
Providence Caregivers
Surveyed in 2013
Over 500 Providers, Nurses, Care Managers and Social Workers
responded
Themes
• Conditions of poverty impact our patient's ability to follow
through with care plans and discharge plans (63% reported
this as true for the majority of their low income patients)
• Staff and providers want more direct pathways/partnerships
with social service partners
• "A community social service provider housed at my clinic or
hospital" would be extremely or very helpful (Top ranked
potential new resource)
Partners
Internal and Community
Providence
Community Partners
Milwaukie Hospital
Milwaukie Foundation
Family Medicine
Residency Program
OR Food Bank
Childhood Hunger
Coalition
Project Access NOW
Familias en Acción
Impact NW
PMG SE/PMG Milwaukie
Community Health Div.
CORE
Project Design
Providence
Who: Families with children ages 0-18
When: Every Well-Child Exam
How: Self-administered questionnaire
while being roomed by the medical assistant
Resources for all families screening positive:
1. Direct connection to a Patient Navigator
2. Local food pantries and food security programs
embedded in the AVS
6
Three Major Components
1. Screening
2. Direct connection to resources for those
experiencing hunger and/or food insecurity
3. Standard protocol, coding & documentation in
EMR for those screening positive
Estimated Patients Vulnerable
to Food Insecurity
Milwaukie Clinic
SE Clinic
Total Patients = 5,900
Total Patients = 5,700
23% on Medicaid
40% on Medicaid
8% Uninsured
8% Uninsured
Roughly 2,000 patients
Roughly 2,800 patients
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Financial Support
Grants
PH & S
Contribution of
Staff Time
Individual
donations
and
sponsorships
Milwaukie
Foundation
approval of
upfront seed
money
Milwaukie
Foundation
Main focus
of their
annual 2014
fundraising
campaign
10
Program Evaluation Component
Children & Families
Staff and Providers
Change in Food Security Status
Awareness of the issue and its
importance
Knowledge of community
resources
Comfort levels with addressing
this issue
Confirmed connection to
Equipped with tools and
programs and resources – Food,
knowledge needed to address the
early childhood, dental, Soc. Serv. issue
Impact on depression & anxiety
Impact on parental level of
distress
Pathways Navigators
Testing a new model of reimbursement
Community Partner is reimbursed based on outcomes
with Project Access NOW administering
Pay Points
 Initial assessment completed – Identify needs and Pathways
 Education, information & referral, appointments set
 Pathways completed – Confirmed connection to services and completion
of goals
 PANOW Web based system generates reporting and tracks outcomes
Screen and Intervene: Success is in the
Details
• Staff and Provider Survey prior to training
• Training:
36 Clinic staff at 2 clinics trained in two 45
minute sessions over lunch
26 Faculty/Resident and Advance Practice
Providers trained. Training incorporated into
afternoon didactics: CBL on FTT and
Childhood Obesity
Clinic and Provider Workflows
• Medical Assistant Role in Screening and
Documentation
• Provider Role in addressing need and
encouraging referrals to Patient Navigator
• Referral Workflows to PANOW and scheduling
appointments. Bus tickets available.
• Follow up reminder calls to families
• Navigator communication back to clinics PRN
Retrieving Data from the EMR
• Where and how to document to be able to
pull data
• Build EMR report to pull data monthly and
report quarterly
• You need a good analyst to build your reports
• Data: Opportunities to screen by provider
(WCC), Total number screened (V code in
problem list), Total positive screens ICD9 994.2
More Data
• Demographic Information: address and zip
codes to identify neighborhood pockets of
need, language, insurance type, age
• Number of referrals to PANOW generated
compared to number enrolled in Pathways.
• Number of completed Pathways
• What are the most prevalent social service
needs of these families beyond food?
Can’t Forget
• Physician Champions in each clinic
• IRB: waivers or expedited review/exemption
request
• $$$$$$$$$$$$
Access to a good grant writer
Financial support from sponsoring hospital
foundation if you can generate interest
Fundraising
Evaluate
• Impact of training on staff/provider
knowledge and comfort levels. Survey again
at 8 – 10 months into pilot.
• Impact on family of Pathway interventions:
parental depression/anxiety, level of distress
in family, ability to seek out and access
resources. Enrollment and discharge surveys
• 2 point of care surveys in the clinics: comfort
with screening and effectiveness of resources
Evaluate and Disseminate Findings
• Is this spreadable to other clinics within the
medical group across the state?
• Is it cost effective? Sustainable?
• Were families comfortable with being
screened and satisfied with resources offered?
• Did staff and provider comfort and satisfaction
with screening change from baseline?
• Publish. Present. Share our experience
References
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Edwards, M. Who is Vulnerable to Hunger in Oregon? Rural Studies Program Fact
Sheet, January 2010. Available at: http://ruralstudies.oregonstate.edu/fact-sheets
Hoisington AT, Braverman MT, Hargunani DE, Adams EJ, Alto CL. Health care
providers’ attention to food insecurity in households with children. Preventive
Medicine. 2012. Available at:
http://linkinghub.elsevier.com/retrieve/pii/S0091743512002551
Accessed July 12, 2012.
Hager ER, Quigg AM, Black MM, et al. Development and Validity of a 2-Item Screen
to Identify Families at Risk for Food Insecurity. Pediatrics, 2010; 126: e26-e32.
Burkhardt, Beck, Conway, et al. Enhancing Accurate Identification of Food
Insecurity Using Quality Improvement Techniques. Available at
http://pediatrics.aappublications.org/content/early/2012/01/11/peds.2011-1153
Klass, Perri. Poverty as a Childhood Disease Available at
http://well.blogs.nytimes.com/2013/05/13/poverty-as-a-childhooddisease/?smid=tw-share...
• Thanks for your interest!
• More questions?
charlotte.navarre@providence.org