APRIL 8, 2014 Better Health. One Connection at a Time. healthleadsusa.org HEALTH LEADS 1

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

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?

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 HEALTH LEADS 2013 PROGRAM HIGHLIGHTS 12

 Executive Champions are Essential  Workflow Matters  Timing Matters 13 KEY LESSONS

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 14 EXECUTIVE CHAMPIONS

 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? 15 WORKFLOW 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 16 TIMING MATTERS

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