CPCA SOCIAL DETERMINANTS OF HEALTH LEARNING COHORT

BACKGROUND

Traditional delivery of health care services has tended to focus on treating medical conditions, and yet a growing body of evidence has demonstrated that social and environmental factors are equally or more important to health outcomes as disease or illness. It is now widely recognized that the health outcomes of populations are more often determined by social factors than by medical care. Much of the most innovative recent work on social determinants and population health demonstrates the value of partnerships across sectors, with health care systems partnering with community-based organizations ranging from housing authorities to nutrition support programs and beyond. 

Given the substantial number of factors involved in these efforts, many health care systems are facing a strategic challenge: what role do they play in the creation and execution of a local population health strategy? This choice is likely to have profound implications for how the system chooses to address the social determinants of health. 

According to Healthy People 2020, Social Determinants of Health (SDOH) are conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes. About 40% of a person’s health are attributed to social factors such as social determinants of health. Community health centers have a history of and commitment to addressing community health needs and have a unique opportunity to delve into assessing and understanding the root causes of poor health such as education, poverty, housing, violence, and other SDOH issues. Health centers are working to understand the need to learn about the social determinants of health affecting their patients in order to fully care for their patients. CPCA is committed to supporting health centers to understand the screening tools available, collecting patient level data with the necessary workflows and lastly to build partnerships and understand the resources in their community to address the SDOH affecting their patients.

SDOH Learning Cohort Overview and Introduction to the PRAPARE Tool – Tuesday, February 27th 
Participants should plan to have all of their team members participate in this webinar. This introductory webinar will provide an overview of what is PRAPARE, what does PRAPARE measure and why SDOH should be addressed. We will cover highlights of lessons learned from previous PRAPARE pilot and discuss the curriculum and logistics of the cohort. What is PRAPARE? What does PRAPARE measure? Why is it important to address SDOH? Lessons Learned from previous CA PRAPARE pilot What’s next: Information on the logistics of the Learning Cohort and review of curriculum Questions/FAQ.

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Recording

SDOH Learning Cohort Webinar # 2 Engaging Key Stakeholders - Thursday, March 29th 10am to 11:30am

This webinar for the CPCA/CP3 SDOH Learning Cohort will focus on best practices and recent lessons learned on engaging audiences (e.g., patients, leadership, staff) in your implementation process along with training on empathic inquiry to assist in collecting data. The training will highlight messaging used by early PRAPARE adopters that worked well with each of those audiences to gather buy-in for implementation (based off of Chapter 2 in the PRAPARE Implementation and Action Toolkit but updated with recent examples harvested from recent PRAPARE implementation efforts). Empathic Inquiry Training to Collect PRAPARE Data covering what empathic inquiry is, why it’s important to use approaches like this for implementation, and demonstrating the difference between empathic inquiry approach and “assessment” approach. This training will also cover Patient-Centered Principles.
Homework prior to this webinar includes reading Chapters 2 in NACHC’s PRAPARE Implementation and Action Toolkit.
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Recording

SDOH Learning Cohort In Person Meeting - Thursday, April 19th 9am to 3:30pm
Participants should plan to have all of their team members participate in this in-person training. This in-person meeting will cover a variety of topics including developing strategies for implementing the PRAPARE Tool, development of work flow models, thinking through your data strategy and how to understand and analyze your data. We will also be discussing the technical implications of implementing the EHR PRAPARE templates, working with local HCCN and EHR vendors, and lessons learned from previous pilot sites. Homework prior to this in-person meeting includes reading Chapters 3 and 5 through 7 in NACHC’s PRAPARE Implementation and Action Toolkit . Also, sites should have downloaded the appropriate PRAPARE EHR template from NACHC. 
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Implementation Workplan

May 2018 – Implementation Month for Data Collection
Participants that have not yet begun to collect data will implement the PRAPARE tool and begin to collect data. Technical assistance will be available from experts and peers to assist you in this process. Participants can refer to Chapter 4 in NACHC’s PRAPARE Implementation and Action Toolkit for resources. Homework will include completion of implementation work plans and submission to Lucy Moreno at lmoreno@cpca.org. This information will be used to identify potential speakers and models to highlight during the August and September webinars. A template will be provided for sites to use if desired. Requests for technical assistance can be sent to Lucy Moreno at lmoreno@cpca.org.

SDOH Learning Cohort Webinar #3 Acting on Data - Tuesday, June 19th 10am to 11:30am 

Participants should plan to have all of their team members participate in this training. Our third webinar will focus on Acting on PRAPARE Data. During this webinar we will delve into responding to the socioeconomic needs of your members. We will begin to think through possible services and interventions. Discussing options to fill gaps in services, whether by building more services in-house or by developing community partnerships including lessons learned from previous pilot sites. Review of resources to help identify and connect members to resources, identify effective interventions and links to other data. (Additional topics may be added based on feedback from participants and lessons learned during the in-person meeting.) Homework prior to this in-person meeting includes reading Chapter 8 and 9 in NACHC’s PRAPARE Implementation and Action Toolkit.
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Recording

July 2018 – Continue Site Data Collection 
Participants will continue to collect data via their electronic health record. Technical assistance will be available from experts and peers to assist you in this process. CPCA will also do individual check-ins with participants to check on progress, successes and challenges to be able to provide any necessary resources or technical assistance for participants. Requests for technical assistance can be sent to Lucy Moreno at lmoreno@cpca.org.

Motivational Interviewing Webinars - July 18th and July 26th
Motivational Interviewing (MI) is an important tool to assist with the initial engagement, help individuals focus, and connect clients to effective treatment plans. The webinar will address the basics of Motivational Interviewing and specifically how MI can be applied to assist clinic staff.
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7/18 Recording
7/26 Recording

SDOH Learning Cohort Webinar #4 Highlights from the Field - Tuesday, August 21st 10am to 11:30am

Participants should plan to have all of their team members participate in this training. This fourth webinar for the CPCA/CP3 SDOH Learning Cohort will focus on Highlights from the Field and a continued discussion on identifying and filling gaps in services for your members including possible presentations from statewide or national organizations that provide services your preliminary data indicates as high needs. (Additional topics or focus areas may be added based on feedback from participants and lessons learned during the in-person meeting and previous webinars.)
Register Here


SDOH Learning Cohort Webinar #5 Highlights from the Field- Tuesday, September 18th 10am to 11:30am

Participants should plan to have all of their team members participate in this training. Our fifth webinar for the CPCA/CP3 SDOH Learning Cohort will focus on additional Highlights from the Field and a continued discussion on identifying and filling gaps in services for your members including possible presentations from statewide or national organizations that provide services your preliminary data indicates as high needs. (Additional topics or focus areas may be added based on feedback from participants and lessons learned during the in-person meeting and previous webinars.) Homework will include completing an evaluation on the learning cohort and submission to CPCA.
Register Here

Resources
Case Studies
Mr. Smith’s Smoking Evolution .  This is very engaging and a good tool to get individuals on board with MI
Brief Action Planning flow chart
Motivational Interviewing Network of Trainers’ resources 
Motivational Interviewing Helping People Change Book, 3rd Ed
Promising Practices
Northeast Valley PRAPARE Tool Cheat Sheet
Northeast Valley PRAPARE Template Screenshots  

Please note: Additional training opportunities including technical assistance on interviewing strategies and techniques along with peer to peer opportunities may be added to the cohort based on feedback and needs expressed by the participants.