Nursing Knowledge and Big Data Initiative Social Determinants of Health

1. Nursing Knowledge and Big Data InitiativeSocial Determinants of Health

2. Authors • Christina Bivona Tellez • Joyce Rudenick • Donnie Toth • Marisa L. Wilson DNScMHSc RN-BC CPHIMS FAMIA FAAN University of Alabama at Birmingham School of Nursing

3. Background • Gathering, collecting, and Using Social Determinants of Health (SDOH) data impact: • Improved patient outcomes • Quality of care • Workflow efficiency at any point of care • Knowledge development • Patient engagement

4. Potential Learning Objectives • Evaluate the importance of social and behavioral determinants of health to patient care      • Describe strategies for optimizing health IT systems to capture and use information about social and behavioral determinants of health of individuals. • Examine the current state of SDOH data standardization. • Provide examples of incorporating social and behavioral determinants of health information into patient care and documentation

5. Potential Modules • Present evidence supporting the collection and use of data. • Explore data collection tools that are valid and reliable. • Discuss workflow implications including the ability to communicate upstream and downstream. • Review issues related to the collection of SDOH including provider and patient participation. • Present current state of projects addressing SDOH. • Consider the role of the nurse as leader of projects addressing SDOH.

6. Potential Teaching/Learning Activities • Read and comment on Institute of Medicine, Robert Wood Johnson Foundation materials. Relate findings to the role of nurse leader. • Discuss tools available to collect SDOH data. Ensure there is a consideration of validity and, reliability of tools and the use of standardized data elements. • Consider local projects that are addressing SDOH and focus on the role of the nurse leadership to those projects.

7. Competency Alignment • AACN Essentials V and VIII -https://www.aacnnursing.org/Portals/42/Publications/MastersEssentials11.pdf • AACN Essentials Revision - Population Health and SDOH https://www.aacnnursing.org/About-AACN/AACN-Governance/Committees-and-Task-Forces/Essentials-Revision • Graduate QSEN Graduate KSAs – Patient Centered Care and Informatics http://qsen.org/competencies/graduate-ksas/ • HITComp Advanced Level, Direct Care and Administrative Roles – http://hitcomp.org/competencies/

8. Considering SDOH is Embedded in ANA Code of Ethics • Provision 8 – The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. • Advances in technology, genetics, and environmental science require robust responses from nurses working together with other health professionals for creative solutions and innovative approaches that are ethical, respectful of human rights, and equitable in reducing health disparities. • Through community organizations and groups, nurses educate the public, facilitate informed choice, identify conditions and circumstances that contribute to illness, injury, and disease, foster healthy life styles, and participate in institutional and legislative efforts to protect and promote health.

9. Landmark Documents • IOM Recommended Social and Behavioral Domains and Measures for Electronic Health Records (2014) http://nationalacademies.org/HMD/Activities/PublicHealth/SocialDeterminantsEHR.aspx • Robert Wood Johnson Medicaid’s Role in Addressing Determinants of Health (2019) https://www.rwjf.org/en/library/research/2019/02/medicaid-s-role-in-addressing-social-determinants-of-health.html • Thornton, M., Persaud, S., (September 30, 2018) "Preparing Today’s Nurses: Social Determinants of Health and Nursing Education" OJIN: The Online Journal of Issues in Nursing Vol. 23, No. 3, Manuscript 5. • WHO Closing the Gap in a Generation (2008) https://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf

10. Examples of SDOH Data Elements • Environment • Stress • Social Isolation • Safety • Domestic Violence • Race • Ethnicity • Veteran status • Refugee status • Income and income distribution • Education • Unemployment • Job security • Food insecurity • Housing • Access to health services • Transportation • Environment

11. Data Sources – Community Level • US Census Data • Birth and Death Records • Tax Assessor Data • City Health Dashboard https://www.cityhealthdashboard.com • County Health Rankings and Roadmaps http://www.countyhealthrankings.org/explore-health-rankings#county-select-38 • CDC Data Set Directory of Social Determinants of Health at the Local Level https://www.cdc.gov/dhdsp/docs/data_set_directory.pdf • CDC Sources for Data on Social Determinants https://www.cdc.gov/socialdeterminants/data/index.htm

12. Data Sources – Individual Level • Collected through screenings, checklists, or surveys (some are valid, some are not) • Can be embedded into the EHR, or a tablet, or PHR, a kiosk, or on paper • Vendors have added SDOH screenings into EHRs • Intimate Partner Violence • Social Isolation • Alcohol and Tobacco Use • Depression • Financial Resources • Food, transport and housing insecurity

13. Tools for Individual Level SDOH Data • Protocol for Responding to and Assessing Patients’ Assets, risks, and Experiences (PRAPARE) from the 15 core and 5 supplemental question Structured data Administered by a clinician or staff http://www.nachc.org/research-and-data/prapare/toolkit/ • CMS Accountable Health Communities Health Related Social Needs Screening Tool Medicare and Medicaid recipients Self administered Covers 5 domains with 8 supplemental domains https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf

14. Tools for Gathering Individual SDOH Data Social Interventions Research and Evaluation Network (SIREN) Collects, summarizes, and compares tools for adults and pediatric populations Has compiled information on the most widely used tools • AHC-Tool • PRAPARE • Health Begins • WellRx • Health Leads • iHELP • MLO IHELP • Your Current Life Situation • Medicare Total Assessment Questionnaire • Seek • NAM Domains • SWYC • We Care https://sirenetwork.ucsf.edu/tools-resources/mmi/screening-tools-comparison/adult-nonspecific du/about-us

15. Issues Related to Individual SDOH Data Collection • What population – Adults? Pediatric? • Do you need a targeted tool? Interpersonal Violence screening in pregnant women Adverse Childhood Experiences (ACE) for children Homelessness • Are the tools validated? • Is there a cost to use the tool? • Is there clinician reticence to collecting the data? • Are there workflow and efficiency issues? • Are the assessments and measures standardized and coded for reuse? https://loinc.org/sdh/

16. The Triple Ss of SDOH • Systematic SDOH collected in all encounters • Structured SDOH via tools • Standardized SDOH using datasets to allow for aggregation and interoperability

17. Optimizing the Collection of SDOH • Identify the population and evidence supported purpose • Practice “empathetic inquiry” • Determine community or individual level data needs • Select if individual level SDOH data, is it clinician or patient entered • Decide if data will be collected as part of a flowsheet, through portal, or on paper • Ensure that SDOH data is incorporated and reported • Use clinical decision support tools (rosters, alerts) • Identify and create referral database • Create referral ordering functions • Use coded, standardized tools • Create data linkages and closed loops

18. National Collaborative to Advance Interoperable SDOH Data • The Gravity Project • https://sirenetwork.ucsf.edu/TheGravityProject • Use cases • Common data elements • Recommendations for capturing the data • Development of FHIR resources • https://sirenetwork.ucsf.edu/sites/sirenetwork.ucsf.edu/files/wysiwyg/Gravity-Project-Charter.pdf

19. Glossary of Terms • Interoperability -  The ability of different information systems, devices or applications to connect, in a coordinated manner, within and across organizational boundaries to access, exchange and cooperatively use data amongst stakeholders, with the goal of optimizing the health of individuals and populations. (HIMSS) • Social Determinants of Health - Conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes.(CDC) • Standards - Standards are agreed-upon methods for connecting systems together. Standards may pertain to security, data transport, data format or structure, or the meanings of codes or terms. (Office of the National Coordinator for Health Information Technology)

20. Resources • Centers for Disease Control and Prevention https://www.cdc.gov/nchhstp/socialdeterminants/resources.html • Institute of Medicine http://nationalacademies.org/HMD/Activities/PublicHealth/SocialDeterminantsEHR.aspx • National Association of Community Health Centers http://www.nachc.org/research-and-data/prapare/ • Social Interventions Research and Evaluation Network (SIREN) University of California, San Francisco https://sirenetwork.ucsf.edu • SIREN – Community Resource Referral Platforms: A Guide for Healthcare Professionals https://sirenetwork.ucsf.edu/tools-resources/resources/community-resource-referral-platforms-guide-health-care-organizations