Good morning and thanks for joining us. I'm Melanie Hall and we're here at the PIC Place.
We've been asked to share with you how we address and assess social determinant factors
and their role that it plays in helping people reach their healthiest self. We believe that
social determinants are a key factor in helping people reach their healthiest self. How much so is
important to understand. In a study conducted by the National Academy of Medicine they found that
health care services alone attributed to only 10 to 20 percent of a person's health outcomes which
leaves 80 to 90 percent that they attributed back to social determinant factors. That's significant
and staggering to consider when we as health care providers are responsible for those outcomes.
So, we need to know what social determinant factors are and how to effectively address them
with patients. The World Health Organization gives us a definition of social determinants.
They are “the conditions in which people are born, grow, work, live, and age, and the wider
set of forces and systems shaping the conditions of daily life”. Wow, when you think about that,
that takes into account all that we are as people but if you think about it outside of
the healthcare environment and more in terms of person to person it makes a lot of sense.
A diabetic patient, maybe one that we take care of here who doesn't have reliable transportation,
struggles with access to healthy food choices, who lives here in this rural environment where
they travel 30 to 45 minutes to see their primary care provider, it's going to be more difficult
for that person to get their A1C into normal range; and without that occurring numerous other
health conditions present. When we understand how important social determinant factors are,
and compare them to how health care is encouraging us to address them, we're presented with lots of
inefficiencies and frustrations. Providers are frustrated, the tools are inadequate, they are
outside of our training, and frankly there's not enough time to do one more thing in a visit with
a patient. Patients, too, are frustrated. They're handed an iPad with a dozen yes or no questions:
do you have reliable transportation, do you have stable housing, and as they answer “no”
to each of those questions, they become more and more disheartened and frustrated. They know that
there are problems within the system. In our community a wait list for subsidized housing
is now closed. Once it reaches 24 months the wait lists close. So to hand them a resource that says
visit your subsidized housing list or office is not going to help them. Here at PIC we are,
for one thing, not willing to accept that that's the best that there is.
We constantly ask is there a better way. Is there a better way that we can
serve patients, serve the staff who work here, and reach the best possible outcome?
We're going to share with you today our Circle of Support which was developed in-house as a way to
address social determinant factors. If nothing else, you're welcome to use it if it fits your
practice, but I'd like it to challenge you and inspire you to ask is there a better way?
To understand what inspired us to create the Circle of Support you have to know first that we
really operate from a belief system. That belief system then helps us craft our approach and then
our resources, our tools, our interventions become the behavior that stems both from that
approach and our beliefs. So we ask ourselves what do we believe and we start from there.
In creating the Circle of Support we first believe that every patient wants to live their healthiest
life. You can see there on the Circle of Support how they are focused right in the middle. They are
not just our partner in this work but they are the lead. They will be needed to be honest in
what their needs are, engaged, and create positive change, and our job is to help them through that
process. We believe poverty and the accompanying social determinant factors are overwhelming.
If you think about what overwhelmed you in the last week imagine that it's the
things that overwhelm our patients: where the meal for their next child would come from,
how they'll stretch the tank of gas over an entire week until they get paid.
Those types of things are overwhelming and hard to know where to start so the tool needs to be
simple. It needs to be organized. It needs to be understood by the patient and those who are
working with them like our staff. It's one page. It's a picture and it factors into our next belief
which is that every employee at our practice has a role to play in social determinants.
It may be the medical assistant, the dental assistant, a provider, a billing staff member that
works with the patient on the Circle of Support. It is something that we choose to partner with
patients, not because of our health care training or background, but simply because we believe that
people need to be worked with as people and the dialogue part of this tool is what's most
important. Although it's everyone's job, it's important to know that successful implementation
requires ownership and a leader. For this reason, it lives within our behavioral health department.
Next, we believe that those who live in poverty have deep reserves of resiliency and innovation.
They've gained this through fighting through adversity. We capitalize on those strengths not
just identify deficits in helping them craft an approach that will help them be their best self.
You'll find that patients will tell you stories of how their trailer park neighborhood
they've created a barter system where one neighbor will take
others to their medical or dental appointments in exchange for their children being watched
in the evening while they go to their shift work. Those are problem solving at its best and it's how
things really get done. They also would not show up on traditional social determinant screeners
so we listen to people and we learn very valuable information that helps us move them forward.
Finally, we believe that this is long-term work.
We are committed to sustainable solutions, helping our patients become problem solvers,
educating them, empowering them, and engaging them in the whole problem-solving process. We work this
into the model by allowing patients to prioritize the top three areas where they want to start
and not surprisingly as Maslow espoused in his model that they start often with a basic human
needs level and move up. We know that there is cost in doing this, that sitting down and having
dialogue with patients is time consuming and expensive, but it really nets exponential gains.
I hadn't really received any training on how to address the psychosocial determinants of health
before I came to PIC and when we introduced the Circle of Support
I couldn't have anticipated how much it would impact my taking care of patients.
One of the first times we did it a patient mentioned that she was having trouble affording
healthy food and that's why her diabetes was uncontrolled. When she said it I realized I had
heard her say that before but because it wasn't in my mind as something that I should address
it had never stuck. I didn't realize she had been saying that before. She'd been
asking for help with her diabetes but not through a prescription for insulin but with
assistance getting healthy food. So since then I've discovered with so many patients that
we as doctors come into the visit with an agenda: I want to get the A1C less than nine, I want to
get the blood pressure at goal, I want to get them taking their inhaler twice a day. And patients can
feel like we're lecturing at them and telling them you have to follow all these rules. But
if we approach the patient as a whole patient the way they are they see themselves, not in the tiny
sliver of time that they're with us but everything happening in their life, and if we address them
in their whole life they feel like we're partners. And they're willing to listen to our advice about
diabetes and COPD because they know we care about where they live and how they're getting food. And
if ever I had any doubt about how much this affects my relationship with patients,
a moment I'll never forget was when the behavioral therapist and I, together,
were doing a Circle of Support on a patient. He has a really severe rheumatologic disease,
clearly medical complications, needs doctors, has been dismissed for being non-compliant,
not always following the rules, and we did the Circle of Support and one of his
repeated main goals and needs was regular food. And I might have understood he needs help with
food but through the conversation what I learned was his sincere goal was to try to make sure he
could eat one meal a day; because sometimes he went days without any food and when we realized
how severe that was like that his health goal was to eat one meal a day we got him a gift card and
it wasn't even for that much but we gave him that gift card so he could get some food. And he sat
there crying because it meant he'd have a meal that day. I realized I need to know my patients
that way before I can influence them in terms of diabetes or the other things that we focus on.
The Circle of Support is really helpful in allowing us to sort of bridge the gap between
medical care and everything else that supports a patient in terms of their full psychosocial
health and having that in place allows us to utilize resources and bring in a whole team
of people rather than just a medical provider and a behavioral health provider in isolation.
As a new provider working here, I had a really hard time at first reconciling the complex medical
needs along with people's chaotic psychosocial situations. And the Circle of Support was really
a great way of bringing other people in and involving them in the patient's medical care and
realizing that I wasn't alone in caring for them and it also allowed me to recognize the resources
in the community really quickly so I'm constantly adding to my toolbox of ideas that I can use
for other patients and I think the Circle of Support really brings that all together
in an easy accessible way. The Circle of Support has also been really helpful
in allowing me to recognize barriers patients have before I start recommending things that are
out of their reach. And so it allows us to more efficiently care for the patient and recommend
interventions and treatments that are actually something that's attainable for the patient.
We have implemented the Circle of Support at The PIC Place since 2018. We knew early on that
we needed to work with patients on the things that were part of their life and so this tool
developed during that time. Originally, we did it just for patients who were risk stratified in
a high risk category. We've since seen the value of it and expanded it to more and more patients.
Just in the last year we worked with the University of San Francisco to code the
screener into our electronic health record so that it can be scaled up and takes a little less
time to complete and update with the patient. We were asked how do we train our staff to do this.
I think the best training is to allow them to experience it. We sit down with a staff member and
take them through this Circle of Support. We're talking about extreme needs today in terms of
social determinants but all of us have them and we could benefit from a plan, a well-organized plan,
a partner that will help us identify goals and keep us accountable and so staff really
see the value as they work through it in their own personal situation. They understand that it's not
a clinically trained position it's simply people being people and reaching out to help one another.
We have a ready source of community resources that we connect people to. It's not just a blanket list
but rather contains insider information like the wait list for affordable housing being closed,
whether or not your citizenship will be asked when you go to a certain organization, if bilingual
staff is available at the food pantry that we send you to. All of those are things that can
potentially create obstacles to people getting the resources that they need. We know our
community partners well whether they're the school counselors at the elementary schools, the area
agency on aging, public transportation because we know that a circle of support is really that
involving different people, different roles, and different organizations to support the patient.
Circle of Support is a different type of tool and so it requires a different type of
measurement and assessment. Think about it like running a marathon. The time from when
you decide to run a marathon you set that goal and the day that you cross the finish line a lot
of time passes. There's opportunity for your motivation to go up and down, for you to have
other priorities that take over your time, and so what we do is we create incremental
efforts that are going to take us from day one to the day of the race. We create running logs. We
map out food plans. We find mentors. And all of this is done to help us measure our efforts that
will help us accomplish the race so that's kind of how we measure our social determinant program.
We measure staff efforts. We measure patient efforts. And trust me the outcomes will follow.
We were awarded a patient family engagement award from CMS at their national conference
in January of 2019. They were looking at the numbers. We cut per member per month
total cost of care by 16 percent, which is pretty unheard of in this high needs population. We had
engaged patients. Our patient satisfaction levels continue to be in the high 90th percentile. We had
cut costs. We had accomplished very positive health outcomes as represented by our CQMs,
and we had created an environment where staff enjoyed doing their job. They knew patients
better. They felt like they had time, which really they had gained only in giving the time
that it took to administer the Circle of Support, but it was creating more meaningful long-lasting
relationships and improving people's health. So I encourage you push the boundaries. If the tool
that's in front of you is not meeting your needs redesign it. Reach out to others. Reach out to
us and let's level up the way that we care for patients so that we reach a healthier community.