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- Augusta Health -

How to Take Control of Your SDOH Data

For the last year, Augusta Health has made a concerted effort to formalize its social drivers of health (SDOH) screening process and take control of its SDOH data. While the ability to meet CMS’s new health equity requirements has certainly been a motivator, it’s ultimately been part of a more significant organization-wide commitment to integrate a health equity lens into everything it does. But as quality leader Megan Howell shares with us, taking on such an enormous—and important—commitment starts with having the right SDOH data tools in place.


When did Augusta Health begin looking at how to collect and use SDOH data?

Megan: The team started collecting SDOH data well before the mandate from CMS. Our organization strongly emphasizes population health, and through our ACO, we’ve prioritized many initiatives, including building community partnerships, leveraging our population health data with the Area Deprivation Index, and meeting quality measures for ACO performance. Those priorities have been a driving force for our case managers wanting to screen for SDOH for some time. Then, in the winter of this year, we formalized and executed an SDOH screening process that aligned with CMS’s health equity mandates and worked within our Meditech EMR for our inpatient population. 


How did you build your SDOH screening tool?

Megan: Before building the tool, we joined the Virginia Hospital and Healthcare Association’s (VHHA) health equity learning collaborative to hear what other organizations around the state were doing around social determinants of health. They did a whole session on how to ask the SDOH screening questions in a way that ensures patients understand the questions and feel comfortable answering them. If you say the word ‘utilities,’ for example, some patients may not know what that word really means—so how can you convey the concept more clearly? We relied heavily on what we learned through that collaboration and the best practices that CMS had released when it came time to create our screening tool.


Where or when do you conduct your SDOH screenings?

Megan: We started with our inpatient case management first. The big concern we had upfront was that it didn’t seem fair to screen patients if we couldn’t provide meaningful resources to help them should they screen positive. Our case managers can do both: ask the questions and connect them to resources.

Then we asked ourselves, ‘Where can we go next to screen as many patients as possible?’ The answer for us was in our ED because that's the access point for many patients.

We're considering expanding the screening to some of our outpatient practices. For instance, we recently had an outpatient surgical patient who had complications in recovery because he was having trouble with his utilities at home. The patient did not have any running water. The team started thinking, ‘Oh my goodness, if we had screened him for these social determinants of health questions, we might have had a better outcome. We know it’s a work in progress, and we can’t do it all at once, so we're trying to implement and prioritize areas that we feel will be most beneficial and impactful for our patients.


Who is responsible for asking the SDOH screening questions?

Megan: Right now, it’s all case managers. We're lucky to have case managers dedicated just to our ED so that they can ask the questions. Eventually, we’d like to reach a point where our nurses can be that point of contact and then refer to case management if a patient screens positive.


You mentioned a quandary that I think a lot of hospitals struggle with: what do we do when a patient screens positive?

Megan: Yes. We were fortunate because we had an official list of community resources before we officially began our SDOH screenings. Our case management staff is small, and they can't, unfortunately, see everybody, so having that list has always been a necessity. Now, it’s just about making team members aware that we have this list of resources; here’s where to find it, and here’s how and when to share it with a patient.


Part of your building process has been integrating your SDOH screening tool into your Meditech EMR and then into your Medisolv ENCOR platform with Medisolv’s Equitable Care Module. How has that process been so far?

Megan: That has been one of our big wins. In our VHHA collaborative, many members are still doing this process on paper, so I was very surprised. I was like, ‘Wow, we're such a small community hospital. I feel like we're ahead of the game.’ The fact that we're asking these questions in our EMR, and then we're able to stratify them in our Medisolv platform by race, gender, ethnicity, and even payer source—it lets us pinpoint opportunities to serve our patient populations better and build clear goals for our 2024 health equity strategic plan.


That’s fantastic progress. So, do you have a sense of what your SDOH screening rates look like right now?

Megan: Yes, I just did a presentation for our meaningful use steering committee, including many of our directors and VPs. I could take our data from quarter three of this year and show them that we had screened 66% of our patients at the hospital, and 6% of these patients screened positive to an SDOH, with transportation needs at 3%. Then I broke it down for them into race, gender, ethnicity, and payor source—which, when we looked at ethnicity, we could see areas of opportunity for the Hispanic or Latino population.


Was that data a big eye-opener for your hospital?

Megan: It was good in that it validated what we already knew. Last year, we implemented a mobile clinic because we knew that this was a population of patients that did not have access to healthcare. The mobile clinic is strategic with the areas and populations it serves and where to provide primary care services. A significant focus is on the Hispanic communities that are uninsured or unable to come to the hospital. This allows us to be more proactive in their care.


That's a great idea. It’s amazing how proactive your team has been in general.

Megan: Thank you. Yes, we have a great team, and this is something I'm really passionate about. Actually, I was the project manager for the mobile clinic, and it's been my favorite project that I've ever been on. It's so meaningful.


Do you have any other interesting health equity initiatives in the works like your mobile health clinic?

Megan: One of the biggest things that happened this year is the Augusta Health Board of Directors embarked on an effort to recraft our organization’s mission statement for the first time in decades. We hoped to refine the mission statement to reflect better the growing importance of health equity and inclusivity in improving health in our community.  We hosted listening sessions with diverse employees and gathered input from community partners and health system leaders through our governance committees.  After multiple revisions, the Augusta Health Board of Directors approved our new mission statement in June. It was very exciting!

We also built a 2023 health equity strategic plan and are working towards our 2024 plan now. We must document our goals and strategic priorities and ensure we’re not just checking a box for CMS’s Hospital Commitment to Health Equity measure.


What are some of health equity goals you’ve identified for 2024?

Megan: If I've learned anything with CMS, it’s that when they put something new out there, it's almost always going to grow. In 2023, they just wanted us to commit to health equity. Next year, they just want us to screen for SDOH. It won’t be long before they want to know what we’re finding in the data and what we’re doing with it.

So, I think that's going to be our most significant focus for 2024: now that we have this [Medisolv Equitable Care] module that tracks everything for us—and other data components like the Area Deprivation Index and our Get with the Guidelines data for Stroke—how will we use this good data to make a meaningful impact? Already, we’re looking at our stroke eCQM data to identify any SDOH barriers to care. We’re also partnering with our various service lines that hold our eCQMs so that we can incorporate the health equity equation into their clinical outcome data. We have real work to do, but we are confident we have the tools to do it.


Do you have any final thoughts for other quality leaders who are trying to build their own SDOH screening process?

Megan: I would say always keep the patient in focus as you develop this process. It starts with the questionnaire. Make sure you’re building and asking the questions in a way that will empower the patient to give you the data you need to help them. And then, look at what kind of assistance or resources you can provide the patient if they screen positive. At the end of the day, it all comes back to patient-centered care.

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