Following is an excerpt from PCCI’s book, “Building Connected Communities of Care: The Playbook For Streamlining Effective Coordination Between Medical And Community-Based Organizations.” This is a practical how-to guide for clinical, community, and government, population health leaders interested in building connected clinical-community (CCC) services.
This section is from Chapter 6, “Clinical Providers Track.” The purpose of the Clinical Providers Track is to set out the stakeholders and processes required to integrate clinical entities, insights, programs, interventions, strategies, and measurement for the CCC.
PCCI and its partner Healthbox, offers readiness assessments as a service. If you and your organization are interested, go here for more information: https://pcci1.wpengine.com/connected-communities-of-care/.
Case Study: Engaging Patients—Location and Relationships Matter
As part of our CCC history, PCCI has developed and tested a number of approaches to identifying individuals within the population of vulnerable and under-served Parkland patients who could benefit from screening for health related social determinants, engaging them in the completion of a brief risk assessment and subsequent linkage to available community resources. As with many of the elements of the CCC, this proved to be a learning experience in which initial, more conventional approaches gave way to new and more innovative approaches of engaging this population to optimize goal
Much of the initial work began with screening in the outpatient setting. Parkland has 12 Community-Oriented Primary Care (COPC) clinics located throughout Dallas County to serve local residents. Because the COPCs see a large number of patients on a daily basis, many of whom are considered vulnerable and underserved, these COPCs were determined to be a great
location to conduct the social determinant risk assessments. When a patient checked in for a visit, the office staff would provide the patient with a paper-based screening tool to self-administer. Trained community health workers were available in the waiting area to help, if required. Initially we felt like this approach made sense since the large number of COPC patients translated into large numbers of completed screening surveys. However, while there were a large number of initial screenings, the number was very low of patients that agreed to engage with a PCCI community health worker to connect with local community services. Many stated they were not interested or needed to leave the facility for another commitment. Other patients completed the needs assessment but left the COPC before staff members were able to connect with them. Of these, very few responded to follow-up phone outreach and the ones that did were hesitant about referral to community-based services. The team attributed this gap to the lack of personal engagement at the point of initial screening.
As a result of this initial experience, the team made some changes to the screening protocols. Three concurrent workflows focusing on different points of patient encounters were designed and tested. The three new points included: (1) engagement while the individual was in the ED, (2) engagement of individuals that had already left the ED, and (3) engagement of hospitalized patients on the medical/surgical floors of the hospital.
For the direct engagement while the individual was in the ED, licensed social workers conducted initial face-to-face screenings with patients awaiting care. The social workers were provided a list of eligible patients (those with multiple ED visits in the past year) and went room to room to conduct the screenings and determine if the patients were interested in connecting with community resources. Because many of these patient interactions took place while the individual was in the middle of an ED care visit, the PCCI team member was mindful of this and stepped aside, as needed, to ensure they didn’t interrupt the patient’s care. For those individuals that left the ED before screening, the PCCI team placed these individuals’ names and contact numbers on a sheet and later reached out to them by phone to explain the program and ask if they were interested in receiving information on community resources.
Finally, for those individuals undergoing an inpatient stay in the hospital, PCCI personnel obtained census data reports with information about eligible patients and then staff visited these patients in their rooms to conduct one-on-one conversations to implement the screening tool and to determine if the patients were interested in receiving more information about navigation services to community resources.
As shown in Table 6.1, a key learning from this undertaking was that the site matters in conducting the screenings and successfully connecting people to local programs for support. We learned that engaging patients during their inpatient stay was the optimal care setting in which to conduct screenings and then connect those patients to the appropriate community resources.
Establishing trust with patients early in the process was essential, both for completing the initial screening tool and for facilitating connection to community services. During our initial approach, we relied on self-administered screenings that provided little in the way of opportunity to establish a relationship with patients. Our modified workflow allowed our social workers and community health workers to verbally administer the screening tool and provide additional explanations as part of that exchange. This process also made the transition to navigation services virtually seamless and much more
effective. Feedback from patients has also been positive; most indicated that the information received was useful and many said they would share this information with other family members and close friends.
THE SCREENING PROCESS
The PCCI community engagement team consisted of six community health workers and two master’s-level, licensed social workers. Initially, the team consisted entirely of social workers, but our experience taught us that a blended staff model was more cost-effective. PCCI physician leaders coached all team members on how to be flexible and professional when working in the ED, where care moves at a rapid pace. The team needed to take cues from medical staff on where and when to step in to conduct the screenings. Similar trainings were delivered to those staff visiting patients in the hospital.
Over the course of the 6-month pilot, we were also able to identify a number of key elements that increased both the effectiveness and efficiency of the screening process. For example, we learned that it took on average 15 minutes to complete the assessment tool when it was facilitated by a team member but only 10 minutes when self-administered. While the self-administered survey took less time to complete, we found a much higher percentage of incomplete and inaccurate responses, making many of the screens useless. As would be expected, we also found that older patients—those 65 or older—took on average 20 minutes to complete the facilitated screening survey while younger individuals completed it in half the time. The difference was attributable to the amount of questions asked and attendant conversations, which were much more prevalent with older patients. Finally, once we began to work more closely with the patients and they developed a better sense of the purpose of the work, we encountered very few issues with obtaining consent from the patients to share their information with others.