SDOH Clinical Care - Local Development build (v0.0.4C1). See the Directory of published versions

Patient Story 1

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The following is a detailed story around the Patient Persona of Rebecca Smith. It provides context around the interactions between and among Rebecca and her care team for the purpose of illustrating the Use Cases defined in this document. Some of the scenarios herein may not fully align with every role or experience in a real-world situation. Please refer to Patient Story 1 Personas for background information around the following four primary roles: patient, physician, care coordinator, and clinical staff member.

Rebecca schedules an appointment for her annual well visit with her primary care physician, Dr. Carla Sanchez. While making the appointment, the scheduler verifies Rebeccas insurance and finds that it covers an SDOH screening. The scheduler confirms Rebeccas preferences for communication. Rebecca consents to use of her email and text for office communications and provides her email address and cell phone number. The scheduler mentions the practice offers a secure patient portal for sharing of clinical information such as test results and visit summaries. She offers Rebecca the opportunity to learn more about the patient portal during the upcoming office visit. Rebecca agrees and the scheduler adds fifteen minutes extra to the appointment for set-up.

One week prior to her appointment, Rebecca receives an email from Dr. Sanchez office inviting Rebecca to complete an online screening questionnaire. The email explains the practice has started asking patients to complete a whole-person health questionnaire as part of the annual well visit. The email details what type of information the questionnaire is collecting, how this information will be used, who would have access to the information, and why it is important to help patients improve and maintain their health. The email clarifies the questionnaire is optional and can be filled out digitally or on paper. Rebecca is given the option to complete the questionnaire online via the patient portal or mobile app, on paper, or at a kiosk at the doctors office. If she needs help with completing the questionnaire either online or in person, she is asked to appear fifteen minutes prior to her scheduled appointment time so a clinical staff member can help her. Since Rebecca has not set up her access to the patient portal, she decides to complete the questionnaire at the doctors office.

Rebecca arrives at Dr. Sanchez office and checks in. The front office staff member, Sylvia Torres, notices Rebecca has not yet filled out the screening questionnaire and asks Rebecca if she received the email about the whole-person health questionnaire. Rebecca confirms she received the email and is willing to answer the questions but needs some help with setting up the patient portal. Sylvia explains Rebecca can complete the questionnaire one of the following three ways: by herself on paper, using the patient portal, or using a new mobile app the practice just rolled out. Rebecca states her preference to complete the questionnaire using the mobile app. Sylvia asks her to sit in the private kiosk area where the training is given.

The clinical staff member, Samir Patel, greets Rebecca at the kiosk station and walks her through the mobile app setup process. He explains the secure mobile app allows the practice to communicate protected health information, so it requires a special step to confirm Rebeccas identity. Mr. Patel helps Rebecca go through a couple of screens to set up her account. He then scans her identification information and uploads it with the account application. He helps her download the app to her phone and gets her started on answering the questionnaire. When Rebecca finishes, Mr. Patel shows her to the exam room. He logs into the EHR and sees Rebeccas responses waiting to be reviewed in her record. He then proceeds to collect and record all of Rebeccas vital signs in the EHR as part of the visit process.

Dr. Sanchez uses her EHR to review the social risk screening responses and Rebeccas past history prior to entering the exam room. She enters the exam room and begins the consult by inquiring how Rebecca has been since their last visit. Rebecca shares that over the past year the family has experienced significant life changes including her recent separation from her husband, who is not paying child support. She notes the frequent moves and the toll this has taken on the family. She tells Dr. Sanchez she has missed three days of work in the past two months from being short of breath from her asthma. She states that even when she is consistent with her medication, she still suffers from acute symptoms. She is struggling to live on one salary to pay for rent, medications, childcare, and food. She feels overwhelmed, guilty, and too tired after work to do anything but get the children fed and ready for the next day.

Dr. Sanchez examines Rebecca and hears scattered expiratory wheezes. She administers a peak flow measurement that reads in the yellow zone. Other clinical details in Rebeccas records showing a recent trip to the emergency room (ER) and two previous acute office visits during the past few months indicate that Rebeccas asthma has worsened.

Dr. Sanchez also notes Rebecca is overweight. Rebecca states she saves money by buying low-cost foods such as macaroni and cheese and pizza. She wishes she could buy more fruits and vegetables, but they are expensive. She also notes that she cannot always afford medications and spaces out her asthma controller medication to every other day instead of every day. Dr. Sanchez inquiries about Rebeccas home environment regarding allergen triggers such as mold or cigarette smoke. Rebecca says no one has been smoking in her apartment and that she does not know if other allergen triggers like mold are present.

To address the asthma concern, Dr. Sanchez and Rebecca identify goals to reduce environmental triggers and reduce the medication cost. Dr. Sanchez reviews the cost of Rebeccas asthma controller medication and determines an equally effective metered dose inhaler (MDI) medication is available. She explains this type of medication does not require electricity for use and can often effectively reduce or eliminate the need for a nebulizer, which could help reduce Rebeccas treatment costs. She presents this alternative to Rebecca, who agrees to try this more affordable treatment option. Dr. Sanchez and Rebecca discuss how Rebecca can respond to exacerbations by adjusting her medications and how she can more effectively control her asthma to prevent acute office or ER visits. They agree on an asthma treatment plan and Dr. Sanchez uses her EHR to document the asthma plan and prescribe the new asthma medication.

Dr. Sanchez is aware that food insecurity is a barrier to weight loss, so she suggests that Rebecca visit a Registered Dietician Nutritionist (RDN) to help her make healthy food choices and unique, positive lifestyle changes. Rebecca responds that this would be helpful to her, so Dr. Sanchez enters the referral order into the EHR.

Dr. Sanchez asks Rebecca if she would like to talk a bit more about her food, housing, and transportation challenges as identified in Rebeccas questionnaire responses. Rebecca is open to this. She confirms these are three areas of concern for her as well, and that she would appreciate any assistance Dr. Sanchez could provide.

To better address Rebeccas non-medical and financially driven needs, Dr. Sanchez refers Rebecca to Reeza Shah, her practices in-house care coordinator. Dr. Sanchez invites Ms. Shah into the examination room and asks Ms. Shah to help connect Rebecca to available resources, either those available in-house or in the community. Ms. Shah can help Rebecca assess her eligibility for federal assistance benefits (e.g., Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)).

Considering Rebeccas transportation needs, Ms. Shah explains that the new asthma medication can be shipped for home delivery. Ms. Shah also confirms Rebecca is eligible to receive an asthma home visit that will help identify environmental triggers in the home. Ms. Shah updates Rebeccas record to include home delivery for the new asthma medication and submits an electronic request for a home visit to assess for asthma triggers.

To address the three social risk factors, Ms. Shah and Rebecca identify the following goals: 1) find more affordable housing solutions; 2) identify and connect Rebecca to food resources and education to help her feed herself and her family well; and 3) check if Rebecca may qualify for transportation assistance to cover trips to the doctor and work. They discuss an action plan to address the goals by working with a care coordinator who will identify and secure available services and supports.

Ms. Shah documents the agreed upon health concerns, patient goals, and action plan (planned interventions and referrals) in the EHR. She asks Rebecca if she would like a copy of the plan and checks to see if Rebecca prefers an electronic or paper copy. Rebecca confirms she would like an electronic copy she can access on her mobile app. Ms. Shah authorizes the EHR to make a copy available in the mobile app.

Mr. Patel returns to the exam room and works with Rebecca to find another date/time to schedule a telephone consultation with Ms. Shah. Mr. Patel schedules Rebeccas appointment with Ms. Shah for the following week and a followup appointment with Dr. Sanchez within three months of the appointment with Ms. Shah so both Dr. Sanchez and Rebecca can monitor the progress with goals established. Rebecca confirms her preference to schedule the appointment after Rebeccas working hours.

The following week, Rebecca has a phone consultation with Ms. Shah. Ms. Shah has reviewed Rebeccas care plan and identified several resources available to support the care plan goals including federal assistance benefits (SNAP/WIC benefits), transportation service to and from appointments, vouchers to cover public transportation (e.g., Commuter Checks), school lunch programs, and a local food pantry. ,

Ms. Shah walks Rebecca through the California SNAP eligibility and enrollment process. Ms. Shah determines Rebecca is eligible for SNAP benefits and offers to assist Rebecca with the SNAP application online or, alternatively, visiting the local SNAP Office. Rebecca confirms she would prefer to apply online and Ms. Shah adds a planned action step to Rebeccas care plan. Rebecca completes and submits the online application the next day during her lunch break.

During the same week, the RDN offices referral team contacts Rebecca to set up a telemedicine consultation with an RDN. Rebecca accepts a date and time that works within her schedule and the referral specialist indicates they will contact her to confirm the appointment one day prior. Ms. Shah contacts Rebecca within one week of their initial consultation and confirms with Rebecca that the SNAP application was submitted. Ms. Shah documents the completed action step in the EHR and confirms the three-month followup appointment with Dr. Sanchez in the EHR. She adds a planned intervention for transportation services and a note that the patient will need a ride to her appointment.

Within two weeks Rebecca receives an email confirmation that her SNAP application has been approved. She also attends the telemedicine appointment with the RDN and receives educational materials and resources as part of that encounter. Rebecca begins to receive SNAP benefits one month later. Over the next month she also receives education on healthier low-cost food options through SNAP Education.

Michael Frank, a community health worker from an organization that provides asthma home visit services, contacts Rebecca by phone to schedule the asthma site visit. The visit is scheduled outside of Rebeccas working hours.

Mr. Frank arrives at Rebeccas house at the agreed upon date and time. He conducts the environmental assessment and discovers there is slight mold in the apartment that is aggravating Rebeccas asthma. Mr. Frank emails Rebecca, Dr. Sanchez, and Ms. Shah a copy of the home-visit report and recommends Rebecca be referred to a housing coordinator. Ms. Shah reviews Mr. Franks report and uploads it into the EHR. Within one week, Ms. Shah emails Rebecca with the name of a housing coordinator (e.g., Metropolitan Housing Agency (MHA)).

One week prior to Rebeccas three-month followup appointment, Mr. Patel receives an alert in the EHR that Rebecca needs transportation services (as documented by Ms. Shah in the previous encounter). Mr. Patel generates an electronic message to Rebecca to confirm she is still in need of transportation. Rebecca confirms via text she still needs transportation services. Mr. Patel schedules a pickup and dropoff from Rebeccas apartment to Dr. Sanchez office. Dr. Sanchez practice has an existing contract with Star Transportation Services. An automated confirmation is sent to the EHR and Rebeccas cell phone on file.

One day prior to the three-month followup appointment, Rebecca receives a text message to confirm the pickup and dropoff time and location. Rebecca confirms the time and address for pickup. Rebecca is picked up the following day by Star Transportation Services and taken to the appointment. During the encounter, Dr. Sanchez collects Rebeccas vital signs, performs a lung function test, and reviews the records sent back from the RDN telemedicine encounter. She notes a 2lb weight loss and a better peak flow. Rebecca confirms she has not had any acute care or ER visits since her last appointment and that she has been able to make healthier food choices based on the RDNs recommendations and through the SNAP benefits and education. Dr. Sanchez asks Ms. Shah to discuss Mr. Franks home visit report results with Rebecca and follow up on the other services and goals they planned during her previous office visit.

Ms. Shah reviews Rebeccas progress toward the goals set during the last encounter. She asks Rebecca about the open action steps she can see in Rebeccas care plan for Rebecca to start a new asthma medication, meet with the housing coordinator, complete a SNAP application, and find more efficient transportation options. Rebecca confirms that she: 1) is consistently taking the less expensive asthma medication; 2) contacted and scheduled a home visit with the housing coordinator Ms. Shah referred her to; 3) completed the SNAP application, is receiving SNAP benefits, and participated in SNAP Education on lower cost healthier food and is starting to feel better; 4) used Star Transportation Services for the followup appointment; and 5) put an inquiry into her employer for public transportation vouchers. Ms. Shah updates Rebeccas care plan in the EHR to mark the medication adherence and completed action steps

Patient Story 1 Assumptions

Assumptions outline what needs to be in place to meet or realize the requirements of the Patient Story. The following are assumptions identified for Patient Story 1.

• Patient lives in a state that incentivizes providers to identify and address social risk factors for low-income or Medicaid eligible patients.
• Patient has health insurance that includes coverage for care coordination services to address the patients social needs.
• Patient is engaged and willing to share information about medical and non-medical needs and concerns (e.g., patient fills new medication order and takes medication as planned, patient calls and schedules home visit with the housing coordinator, patient is able to articulate social needs clearly).
• Patient has a high school level or greater literacy and comprehension level.
• Patients preferred language is English.
• Patient has access to health carecan schedule annual wellness visit during after work hours while her children are in daycare.
• Patients information will be shared and accessed in compliance with a policy and regulatory framework (e.g., privacy and security) and Patient Consent Directives.
• Patient has mobile phone with text messaging and email capabilities.
• Patient has access to patient portal and can use portal to review and update electronic information.
• Patient supplies a valid ID to the practice and the practice uses it to create a trust account. The account uniquely identifies the patient to communicate and share information in a secure manner.
• Patient interprets screening questions as intended and answers questions honestly.
• Questions presented in the screening questionnaire are a subset of value sets needed to document SDOH.
• Evidence-based patient engagement strategies are used to communicate with the patient and to gather information from the patient.
• Quality clinical documentation is used to assign the appropriate medical codes (e.g., LOINC, SNOMED CT, ICD-10, CPT) to capture the SDOH data.
• Patient is eligible for and is approved to receive community-based services. Service capacity exists to address the patients social needs.
• Transportation services are offered to the Primary Care Physicians (PCP) patient once a need is identified by the Clinical Staff as part of the screening process.
• PCP offers late afternoon appointments once a week to accommodate different work schedules.
• PCP covers the cost of transportation for the patient. For example, the practice may be eligible to use transportation vouchers provided by the state and/or a private insurer.
• Patient leads and/or directly engages in the creation of goals to address the health concerns and social needs identified through the care planning process.
• PCP initiates and documents the clinical and social need care planning activities in the EHR. The Care Coordinator reviews, manages, and monitors the action plan to address the social needs.
• Patient has the ability to verbally grant consent to selected Care Team Members to view the patients care plan.
• Patient and Care Team Members have the ability to define notifications and designate notification recipients.
• The Care Coordinator is the facilitator/steward who is responsible for reviewing and reconciling proposed modifications to the care plan.
• Patients followup appointment is scheduled during the patients lunch break.
• Necessary access and entry authorization protocols, for any of the systems or users described, are in place.
• Screening information can be accessed and retrieved in a structured and coded format.
• Patient encounter data will be used to generate a claim to the payer.
• EHR is capable of storing captured data and associating it with the specific patient and encounter as part of the permanent medical record.
• EHR is capable of transmitting care coordination documentation (e.g., referral note, consult note, care summary, care plan) either in the HL7 Clinical Document Architecture (CDA) or HL7 Fast Health Interoperability Resources (FHIR) format.
• EHR has access to all Patient social risk related screening, diagnosis, goal setting, and intervention data.
• EHR is capable of incorporating SDOH data for both encounter and claims-based data exchange with a payer.
• Each of the entry modalities either tie back to a common, singular database, or if they are separate databases, the data elements are consistent across each and the integration is preferably automated and near real-time.
• Acknowledgment and error-handling messages will be handled by standard IT protocols and will not be addressed within the scope of this Use Case Package.

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