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The Role of Primary Care Clinics in Addressing the Social Determinants of Health

This conference presentation discusses the importance of addressing social determinants of health in the community, models and approaches to address them, and clinic principles and practices to address social determinants of health. It emphasizes the need for primary care clinics to incorporate community change and advocacy into their practices, establish relationships with community resources, and offer integrated, coordinated, and whole-person care.

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The Role of Primary Care Clinics in Addressing the Social Determinants of Health

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  1. The Role of Primary Care Clinics in Addressing the Social Determinants of HealthKenneth D. Smith, Ph.D.Health Systems Transformation ConsultantOffice of Health Policy and Legislative Affairs Texas Association of Charity Care Clinics Conference April 20, 2018

  2. Objectives • Importance of Addressing the Social Determinants of Health in the Community • Models and Approaches to Addressing the Social Determinants of Health • Clinic Principles and Practices to Address the Social Determinants of Health and the Community Level • Interactive Activity: What Can Your Organization Put into Practice?

  3. Social context matters

  4. Place matters • Health is a complex equation based on a number of inputs leading to a number of outputs but in the end indeed place matters: • Where people Live • Where peopleLearn • Where people Work • Where people Play • Where people Pray • Where people Transport

  5. Changing the Social Context Multiple health care providers in an area operate as partners to improve the health of all residents by engaging a broad set of partners outside of healthcare Health care providers incorporate community change and advocacy into their formal practices to improve the living and working conditions of their patients Health care providers establish relationships with community resources to link patients to resources for health improvement or social needs Health care providers offer integrated, coordinated, and whole-person care for all stages of life Sources: American Academy of Family Physicians, CDC, Prevention Institute

  6. Practices for Community-Clinic Linkages • Mrs. M. had a chronic headache. She visited 3 ERs in one month, but still had no diagnosis nor treatment. • Overall, she had: 2 CAT scans of her head 1 Lumbar puncture Multiple blood tests Pain medicines Out-of-pocket charges Missed work Lost income AND SHE WAS STILL SICK

  7. Why Screen for Patient Social Needs? • Some causes of illness, such as mold in the home, aren’t obvious in the exam room • Improve diagnosis and treatment • Address underlying social determinant of health • Link clinic with community • Understand patients’ social needs • Become involved in addressing root causes of those needs

  8. Screen for Social Needs CCL Practices and Approaches How? With whom? Match with Services How? Which ones?

  9. Community Centered Health Home “Model” • A Community-Centered Health Home not only acknowledgesthat factors outside the clinic walls affect patient health outcomes, it actively participatesin improving them.

  10. CCHH Early Pilot Testing NC TX AL MS LA FL

  11. The CCHH Model: Rooted in the Health Center Movement Prevention Institute’s CCHH Report (circa 2011) Drs. Jack Geiger & John Hatch Tufts-Delta Health Center (circa 1968) Photo Credit: Daniel Bernstein

  12. Core Lessons Learned from the Nation’s First Health Centers • Medically-underserved communities are rich in potential, as well as bright & creative people whose talents can be harnessed to the Health Center program. • CHCs have the capacity to attack the root causes of ill health through community development and the social change it engenders. • - H. Jack Geiger (AJPH 2002) Photo Credit: Daniel Bernstein

  13. Texas CCHH Initiative At a Glance • $10 million, 4-year initiative • 13 Texas Community Health Centers • 2016: Invitation & orientation to the initiative • January-June 2017: Action Planning Grant period • July 2017: Cohort Period Grant –two grantee cohorts • Capacity Building: 18 mos ($100k-150k) • Implementation: 3 years ($100k-300k) This initiative is part of a larger national effort that is testing the model in other regions. FL

  14. Health Center Core Capacities for building a CCHH

  15. CCHH: Moving Prevention Further Upstream

  16. CCHH Builds Upon Primary Care

  17. CCHH Model Coordinate activity with community partners Advocate for community health Mobilize patient populations Strengthen Partnerships Establish model organizational practices Collect data on social, economic & community conditions Aggregate prevalence data Review health & safety trends Identify priorities & strategies with community partners ACTION INQUIRY ANALYSIS

  18. Group Activity • Is your clinic implementing any of these core principles and practices already? • What capacities do you already have to support this approach?

  19. Thank you!

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